Application To Vote By Mail Form - Adams County, Illinois printable pdf download

Vote by Mail Application

ADAMS COUNTY, ILLINOIS

Application Number

Voter ID #

Staff Initials

(FOR OFFICE USE ONLY)

Precinct

Ballot Style

Applicant’s Name (Please Print)

________________________________________________

Street Address

________________________________________________

City, State, Zip

________________________________________________

County

________________________________________________

Date of Birth*

________________________________________________

Phone Number*

________________________________________________

E-Mail*

________________________________________________

To be voted at the

________________________________________________ Election

Date of Election

________________________________________________

Precinct

________________________________________________

*Optional information; Even though this is not required, providing it may aid in the processing of your ballot

I certify that I reside at the address specified above, in the stated precinct and county, that I have lived at such ad-

dress for 30 days or more preceding this election, that I am lawfully entitled to vote in such precinct at said election to be held

therein, and that I wish to vote by absentee ballot.

I hereby make application for an official ballot or ballots to be voted by me at such election, and I agree that I shall

return such ballot or ballots to the official issuing the same prior to the closing of the polls on the date of the election or, if re-

turned by mail, postmarked no later than midnight preceding election day, for counting no later than during the period for

counting provisional ballots, the last day of which is the 14th day following election day.

I understand that this application is made for an official vote-by-mail ballot or ballots to be voted by me at the election

specified in this application and that I must submit a separate application for an official vote-by-mail ballot or ballots to be

voted by me at any subsequent election.

Address to which ballot is to be mailed (If different from above)

(Date)

(Signature of Applicant)

Upon completion, mail this application to: Chuck R. Venvertloh

Adams County Clerk

507 Vermont St

Quincy, IL 62301

Application To Vote By Mail Form - Adams County, Illinois

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