Please print out this application and write clearly.
Please read all instructions below and complete all applicable fields.
This application must either be personally delivered to Middletown Thrall Library no later than the day before the election, or postmarked by a governmental postal service not later than the 7th day before election day. The ballot itself must be received at Middletown Thrall Library no later than the close of polls on election day.I am requesting, in good faith, an absentee ballot due to (please check one reason):
[ ] absence on election day
[ ] temporary illness or physical disability
[ ] permanent illness or physical disability
[ ] duties related to primary care of one or more individuals who are ill or physically disabled
[ ] patient or inmate in a Veterans' Administration Hospital
[ ] detention in jail/prison, awaiting trial, awaiting action by a grand jury, or in prison for a conviction of a crime or offense which was not a felony
Your Last Name, Surname: _______________________________________
First Name: _______________________________________
Middle Initial: _____________
Suffix: _____________
Date of Birth (month / day / year): ____________________________
County Where You Live: _______________________________
Telephone Number (optional): _______________________________
Street Address: ________________________________________________________
Apt.: ______________
City: _______________________________
State: _______________________________
Zip Code: _______________________________
Delivery of Election Ballot - Please Mail Ballot to Me at the Following Address:
Address: ______________________________________________________________
Applicant Must Sign Below
I certify that I am a qualified and a registered voter; and that the information in this application is true and correct; and that this application will be accepted for all purposes as the equivalent of an affidavit; and if it contains a material false statement, shall subject me to the same penalties as if I had been duly sworn.Please Sign Here: ____________________________________________
Date: _______________________________
If applicant is unable to sign because of illness, physical disability, or inability to read, the following statement must be executed: By my mark, duly witnessed hereunder, I hereby state that I am unable to sign my application for an absentee ballot without assistance because I am unable to write by reason of my illness or physical disability or because I am unable to read. I have made, or have the assistance in making, my mark in lieu of my signature. (No power of attorney or preprinted name stamps allowed.)
Date: _______________________________
Name of Voter: __________________________________________
Mark: ________________________________
I, the undersigned, hereby certify that the above named voter affixed his or her mark to this application in my presence and I know him or her to be the person who affixed his or her mark to said application and understand that this statement will be accepted for all purposes as the equivalent of an affidavit, and, if it contains a material false statement, shall subject me to the same penalties as if I had been duly sworn.
Address of Witness to Mark:
______________________________________
Signature of Witness to Mark:
______________________________________