HomeMy WebLinkAboutAbsentee Application.docVOTE IN OFFICE PERMANENT THIS ELECTION ONLY
REGISTERED X EOG ~BEE WARD 1t DISTRICT
APPLICATION FOR ABSENTEE BALLOT
1. ALL PERSONS REQUESTING AN ABSENTEE BALLOT MUST COMPLETE THIS SECTION AND SIGN IN SECTION 4 BELOW:
I Request that an absentee ballot be sent to me for the Primary/Election to be held on APRIL 6 ~ 20 04
I certify that I am a United States Citizen, age 18 or older, and that I have resided at the following address which is my legal voting
address for at least 10 days before the election for which I am applying for an absentee ballot.
Name MARILYN STEWART
Address 1645 CEDAR STREET
Mail/Deliver Ballot to:
Name
Street Address
Municipality. State Zip
2. INDEFINITELY CONFINED ABSENTEE ELECTOR REQUESTING AN AUTOMATIC BALLOT FOR EACH ELECTION MUST CHECK
THE BOX BELOW: (NURSING HOMES)
__1 further certify that I am indefinitely confined because of age (at least 70 years old), illness, infirmity or disability. I request that an
absentee ballot be automatically provided for every election until such time as I notify you or until such time as I fail to return an absentee
ballot.
3. HOSPITALIZED ELECTOR REQUESTING AN ABSENTEE BALLOT BY AGENT MUST CHECK THE BOX AND COMPLETE THE
FOLLOWING:
__ I certify that I can not appear at the polling place on election day because I am hospitalized.
I appoint to serve as my agent pursuant to s.686(3), Wis. Stats.
WITNESS
Signed Address
AGENT
I certify that I am the duly appointed agent of the hospitalized absentee elector, that the absentee ballot to be received by me is received
solely for the benefit of the above named hospitalized elector, and that such ballot will be promptly transmitted by me to that elector and
then returned to the municipal clerk or the proper polling place.
Signed Address
4. ALL REQUESTS MUST BE SIGNED BY ELECTOR.
SIGNATURE OF ELECTOR REQUESTING ABSENTEE BALLOT
EB-121 (Rev. 6/88) The information on this form is required by ss. 6.85 6.87 Wis. Stats. This form is prescribed by the State Elections Board, 132 E. Wilson St., Madison, WI 53702
(608) 266-8005. Proving false information on this form is punishable by a fine of $1,000, imprisonment of six months or both. Ss. 12.13 (1)(b), Wis. Stats.
**Removed reason for application due to election law change 8/15/00