Fillable Eb-121 - Wisconsin Application For Absentee Ballot printable pdf download

Wisconsin Application for Absentee Ballot

SVRS ID #

Confidential Elector ID#

(HINDI - sequential #) (Office Use Only)

(Office Use Only)

Please use uppercase (CAPITAL) letters only. Fill in circles as appropriate. Return completed form to municipal clerk.

General Instructions:

This document can be made available in accessible formats to persons with disabilities, upon request.

Please Review Fully

Voter Declaration: I certify that I am a qualified elector, a U.S. citizen, at least 18 years old, having resided at the below residential address for at

least 10 days immediately preceding this election, not currently serving a sentence including probation or parole for a felony conviction, and not

otherwise disqualified from voting.

Required Information

(NOTE: In order to receive an absentee ballot, you must be a registered elector)

Town

Municipality

Village

City

County

Last Name

Suffix

(e.g. Jr, II, etc.)

First Name

Middle Name

Date of Birth

Telephone

(MM/DD/YYYY)

Residence Address: Street Number & Name

Apt. Number

City

State

ZIP + 4

(WI Only)

If Mailing Address is different than the Residence Address, Send Ballot To:

Name

Nursing Home Name (If applicable)

Mailing Address: Street Number & Name

Apt. Number

City

State & ZIP + 4

Elections (select one of the following options):

I request that an absentee ballot be sent to me for the election(s) on the following date(s): ________________________________________

I request that an absentee ballot be sent to me for all elections from today’s date through the end of the current calendar year (ending 12/31).

I certify that I am indefinitely confined because of age, illness, infirmity or disability, and request an absentee ballot be sent to me for every

subsequent election until I am no longer confined or fail to return a ballot for an election.

If you are a military or overseas elector, fill in the appropriate circle (see instructions for definitions):

Military

Overseas

Hospitalized Voter Information

(Only for those electors who are not indefinitely confined; 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 s.6.86(3), Wis. Stats:

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 transmitted by me to that elector

and then returned to the municipal clerk or the proper polling place.

Agent Signature

Agent Address

WITNESS: I certify that I am a resident of this absentee elector’s municipality, and that the statements contained in this application are true

to the best of my knowledge.

Witness Signature

Witness Address

Date

(MM/DD/YYYY)

Signature of Elector

Office

Ward

Sch. Dist.

Alder.

Cty. Supr.

Ct. of App.

Assembly

St. Senate

Congress

Other

Use

Only:

THE INFORMATION ON THIS FORM IS REQUIRED BY SS.6.85, 6.86, 6.87, WIS. STATS. PROVIDING FALSE INFORMATION ON THIS FORM IS PUNISHABLE BY A FINE OF $1,000,

IMPRISONMENT OF 6 MONTHS OR BOTH SS.12.13(3)(1), 12.60(1)(B), WIS STATS.

EB-121 WITHOUT HASH MARKS (REV 2/2008)

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