Gab-121 - Wisconsin Application For Absentee Ballot
ADVERTISEMENT
1
2Wisconsin Application for Absentee Ballot
Confidential Elector
lD#
(HlNDl - seouential #) (Atficial Use
Onlv)
WiSVOIE ID
#
(Ofiicial
Use
Only)
Ward
No.
.
e
o
o'
=
@
Detailed
instructions for completion
are on
the
back of
this form.
Return
this form to your municipal
clerk
when
completed.
.
You
must be registered
to
vote before you can receive an absentee
ballot.
You can confirm your voter registration at
A
effOfO
lD
REQUIRED, unless you qualify for an
exception.
See instructions on back for exceptions.
VOTER INFORMATION
1
Municipality
O
ro*n
Q
vittage
O
ciiy
County
2
Last Name
First Name
Middle Name
suffix,"qr,*.'
I
lDate""ofBirth
Phone
Fax
Email
3
Residence
Address:
Street Number
&
Name
Apt.
Number
City
I
state
a
zre
4
lf
you are a milttary or permanent overseas eleclor,
fill
in
the appropriate circle (see instructions for
definrtions):
Q
tr,lititary
Q
PermanentOverseas
I PREFER
TO
RECEIVE MY
ABSENTEE BALLOT
BY:
(Ballot
will
be mailed to
the
address above if no preference is indicated.
Absentee
ballots
may
not be
foMarded.)
5
O
vnt
Mailing
Address: Street
Number & Name
VOTE
IN
O
clrRx's
OFFICE
Apt.Number
I
lcitv
State
&
ZIP
Care
Facility
Name (if applicable)
C/O(ifapplicable)
O rnx
Fax Number
O rrunu
Email Address
I REQUEST
AN ABSENTEE BALLOT
BE SENT
TO
ME
FOR:
1ma*
onty one)
b
Q
fne
election(s)
on the following date(s):
Q
All
electionsfromtoday'sdatethroughtheendofthecurrentcalendaryear(ending12/31).
O
everyelectionsubsequenttotoday'sdate. lfurthercertifythatlamindefinitelyconfinedbecauseofage,illness,infirmityordisabilityand
request
absentee ballots be sent
to
me
until
I
am no longer confined or
fail
to return a ballot.
TEMPORARILY
HOSPITALIZED VOTERS
ONLY
(please
fillin
circle)
7
Q
t
certify
that
I
cannot
appear
at the polling place on election day
because
I
am hospitalized,
and
appoint the
following
person
to
serve as
my agent, pursuant to
Wis.
Stat.
S
6.86(3).
Agent Last
Name
Agent First
Name
Agent Middle
Name
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
transmifted
by me to that
elector
and
then
returned to
the
municipal clerk or
the
proper polling place.
Agent Signature
x
Agent
Address
ASSISTANT
DECLARATION
/
CERTIFICATION
(if required)
I
certify that the application
is
made on request and by authorization
of
the named elector, who is unable to sign the application due
to
physical disability.
Agent
Signature
x
Today's
Date
VOTER
DECLARATION
/
CERTIFICATION
(required
for all
voters)
I
certify that
I
am
a
qualified elector, a U.S. Citizen, at least
18
years old, having resided
at
the above residential address for at least
10
consecutive days
immediately preceding this election, not currently
seMng
a sentence including probation or parole for
a
felony conviction. and not otherwise disqualified
from
voting.
Please
sign
below to acknowledge that you have
read
and understand the above.
Voter
Signature
x
Today's
Date
EL-121
| Rev2016-08
|
Wisconsin Electons Committee, P.O.
Box
7984, Madison,
Wl
53707-7984
|
608-266€005
lweb: elections.wi.sov
I
email:
elections@lrti.qqv
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business