State Of Iowa Official Absentee Ballot Request Form Page 2
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1
2COLLINS-MAXWELL COMMUNITY SCHOOL DISTRICT
S
I
O
V
R
F
TATE OF
OWA
FFICIAL
OTER
EGISTRATION
ORM
Revised 4/9/2014
In Iowa, you are not qualified to vote if you have been convicted of a felony and have not received a
restoration of voting rights. You may apply to the Governor to restore your voting rights.
VOTE ON SEPTEMBER 8, 2015
$8.175 MILLION BOND REFERENDUM + INCREASE THE PHYSICAL PLANT AND EQUIPMENT LEVY BY $0.67
1.
Are you a citizen of the United States?
Yes
No
Qualifications
2.
Will you be 18 years of age on or before Election Day?
Yes
No
VOTING INFORMATION
If you answered “No” to either of these questions, do not complete this form.
STORY COUNTY POLLING PLACES
ID Number
IA driver’s license #:
SPECIAL ELECTION SEPTEMBER 8, 2015
Provide your Iowa
POLLING HOURS: 12NOON UNTIL 8:00 P.M.
driver’s license, non‐
IA non‐operator ID #:
operator ID number,
or the last 4 digits of
COLLINS AREA COMMUNITY CENTER
MAXWELL AREA COMMUNITY CENTER
Last 4 digits of Social Security number: XXX – XX –
your Social Security
219 Main Street
84 Main Street
number if you have
I do not have an IA driver’s license, non‐operator ID, or Social Security number.
one.
Collins, IA 50055
Maxwell, IA 50161
Additional
Date of Birth
/ /
HOW TO REGISTER TO VOTE
(month, day, year)
Information
Gender
Male
Female
Date of birth and
•
You may register by mail or in person to vote in this election. If by mail, complete a Voter Registration Form (on left) and
gender are required.
Phone and/or Email
(optional)
mail to the Story County Auditor’s Office to arrive no later than August 28, 2015. After August 28, Election Day Registration
Rules apply.
Last
•
After August 28th you may only register in person at the Auditor’s Office or at the polling location on September 8, 2015.
Your Name
First
You will be required to show proof of identity and proof of residence.
•
Auditor’s Office hours:
Middle
Suffix
•
Weekdays: 8:00 a.m. to 5:00 p.m.
Street Address
•
Closed Monday, September 7, 2015 in observance of Labor Day
Address
(include apt., lot, etc.)
Where You
HOW TO VOTE BY ABSENTEE BALLOT
City
Zip
County
Live
If homeless or you do not have an established residence, describe where you reside:
VOTING ABSENTEE BALLOT
IN PERSON
•
Go to the Story County Auditor’s Office until 11:00 a.m. on Tuesday, September 8, 2015.
Where You
Address/P.O. Box
•
Auditor’s Office hours:
Receive Mail
•
Weekdays: 8:00 a.m. to 5:00 p.m.
City
State
Zip
(if different)
•
Closed Monday, September 7, 2015 in observance of Labor Day
Previous
Your name was
Voter
VOTING ABSENTEE BALLOT
BY MAIL
Your address was
Registration
•
Complete an absentee ballot request form (on back) and return to the Story County Auditor’s Office no later than 5:00 p.m.
Information
on Friday, September 4
Your city and state were
Your zip was
•
Mail back the completed absentee ballot request form in the enclosed envelope OR drop it off at the Story County
Political
Political Parties:
No Party
Democratic
Republican
Auditor’s Office
Affiliation
•
Non‐Party Political Organizations:
Green
Libertarian
Go to the Story County Auditor’s Office until 11:00 a.m. on Tuesday, September 8, 2015.
(check only one)
To register to vote and/or obtain an absentee ballot request form, see the Story County Auditor’s Office or download the forms
WARNING
Registrant Affidavit
from the following website:
If you sign this
I swear or affirm under penalty of perjury that:
form and you
I am the person named above.
know the
QUESTIONS?
I am a citizen of the United States.
information is
Contact the Story County Auditor’s Office at (515) 382-7210
I have not been convicted of a felony (or I have received a restoration of rights).
not true, you
I am at least 17 ½ years old.
may be
I live at the address listed above.
Story County Auditor
convicted of
I am not currently judged by a court to be “incompetent to vote.”
900 Sixth Street
perjury and
I do not claim the right to vote anywhere else.
fined up to
Nevada, IA 50201
$7,500 and/or
jailed for up to
ADDITIONAL INFORMATION
5 years.
Signature
Date
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