Minnesota Absentee Ballot Application Form - 2016 printable pdf download

2016 Minnesota Absentee Ballot Application

Apply Online at

-OR-

Complete lines 1 through 7 below. Please print clearly.

Return this application as soon as possible. Ballots must be returned by election day to be counted.

Important: Active duty military and overseas voters should not use this application. See the other side for more information.

absentee ballots requested for the following election(s)

(if no election is marked, a ballot will be mailed for the next election only)

special primary - specify date:

both primary and general election

special election - specify date:

primary only

general election only

middle name

suffix

first name

last name or surname

date of birth (mm/dd/yyyy)

county where you live

phone number

email address

mark all boxes that apply:

I have a MN-issued driver’s license or MN ID card. The number is:

XXX-XX-

I have a social security number. The last four digits are:

I do not have a MN-issued driver’s license, MN-issued ID card or a social security number.

Your identification number will be compared to the one on your absentee ballot envelope.

address where you live (residence)

apt.

city

zip code

address where your absentee ballot should be sent

apt.

city

state

zip code

I certify that I:



am completing this application on my own behalf;



will be at least 18 years old on election day;



am a citizen of the United States;



will have resided in Minnesota for 20 days immediately preceding election day;



maintain residence at the address given on this application form;



am not under court-ordered guardianship in which the court order revokes my right to vote;



have not been found by a court to be legally incompetent to vote;



have the right to vote because, if I have been convicted of a felony, my felony sentence has expired (been completed) or I

have been discharged from my sentence; and



have read and understand this statement: The above information is accurate, and I sign this application form under penalty

of perjury, a felony punishable by not more than 5 years imprisonment, a fine of not more than $10,000, or both

X__________________________

____/____/____

sign here:

date

See other side for special instructions for voters with disabilities or power of attorney.

official use only

reason replaced

Primary

received date

ballot issued date

initials

type

repl. date:

precinct

rejected

 lost

reg

spoiled

M C HCF

never received

non-reg

reason replaced

General

received date

ballot issued date

initials

type

repl. date:

school district

rejected

 lost



reg

spoiled

M C HCF

never received



non-reg

Minnesota Absentee Ballot Application Form - 2016

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