Wisconsin Application for Absentee Ballot
SVRS ID #
Confidential Elector ID#
(HINDI - sequential #) (Office Use Only)
(Office Use Only)
Instructions for completion are on the back of this form. Return this form to your municipal clerk when completed.
Please use uppercase (CAPITAL) letters only. Fill in circles as appropriate.
You must be registered to vote before you can receive an absentee ballot. You can confirm your voter registration at
https://myvote.wi.gov
VOTER INFORMATION
O
Town
1
Municipality
County
O
Village
O
City
Last Name
First Name
2
Date of Birth
Middle Name
Suffix
(e.g. Jr, II, etc.)
(MM/DD/YYYY)
Phone
Fax
Email
3
Residence Address: Street Number & Name
Apt. Number
City
State & ZIP
4
If you are a military or permanent overseas elector, fill in the appropriate circle (see instructions for definitions):
Military
Permanent Overseas
I PREFER TO RECEIVE MY ABSENTEE BALLOT BY:
(Ballot will be mailed to the address above if no preference is indicated)
MAIL
Mailing Address: Street Number & Name
CLERK’S
City
State & ZIP
Apt. Number
5
OFFICE
Nursing Home Name (if applicable)
C / O (if applicable)
Military and Permanent Overseas only
Military and Permanent Overseas only
Fax Number
FAX
Email Address
Military and Permanent Overseas only
EMAIL
(required for email or
Military and Permanent Overseas only
ONLINE
online delivery)
I REQUEST AN ABSENTEE BALLOT BE SENT TO ME FOR:
(mark only one)
The election(s) on the following date(s): ____________________________________________________________________________
All elections from today’s date through the end of the current calendar year (ending 12/31).
6
Every election subsequent to today’s date. I further certify that I am indefinitely confined because of age, illness, infirmity or disability and
request absentee ballots be sent to me until I am no longer confined or fail to return a ballot.
TEMPORARILY HOSPITALIZED VOTERS ONLY
(please fill in circle)
I 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. § 6.86(3).
Agent Last Name
Agent First Name
Agent Middle Name
7
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.
X
Agent Signature
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
X
Today’s Date
Signature
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 28 consecutive days
immediately preceding this election, not currently serving 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
X
Today’s Date
Signature
GAB-121 | Rev 2013-11 | Government Accountability Board, P.O. Box 7984, Madison, WI 53707-7984 | 608-261-2028 | web: gab.wi.gov | email: gab@wi.gov