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Pleaseprintclearly.Seedetailedinstructions.
Town/City/Ward/Dist:
Thisapplicationmusteitherbepersonallydeliveredtoyourcountyboardofelectionsnot
laterthanthedaybeforetheelection,orpostmarkedbyagovernmentalpostalservice
notlaterthan7thdaybeforeelectionday.Theballotitselfmusteitherbepersonally
deliveredtotheboardofelectionsnolaterthanthecloseofpollsonelectionday,or
postmarkedbyagovernmentalpostalservicenotlaterthanthedaybeforetheelectionand
receivednolaterthanthe7thdayaftertheelection.
1.
3.
4.
5.
6.
Party: ____________________________
voted in office
Iamrequesting,ingoodfaith,anabsenteeballotdueto(checkonereason):
2.
_________________________________
absencefromcountyorNewYorkCityonelectionday
temporaryillnessorphysicaldisability
permanentillnessorphysicaldisability
dutiesrelatedtoprimarycareofoneormore
individualswhoareillorphysicallydisabled
patientorinmateinaVeteransAdministration
Hospital
detentioninjail/prison,awaitingtrial,awaiting
actionbyagrandjury,orinprisonforaconviction
ofacrimeoroffensewhichwasnotafelony
absenteeballot(s)requestedforthefollowingelection(s):
PrimaryElectiononly
GeneralElectiononly
SpecialElectiononly
Anyelectionheldbetweenthesedates:absencebegins:_____/_____/_____absenceends:_____/_____/_____
lastnameorsurname
firstname
dateofbirth
countywhereyoulive
______/_____/_____
middleinitial
suffix
phonenumber(optional)
addresswhereyoulive(residence)street
apt
city
state
zipcode
NY
DeliveryofPrimaryElectionBallot(checkone) Delivertomeinpersonattheboardofelections
Iauthorize(givename):_______________________________________topickupmyballotattheboardofelections.
Mailballottomeat:(mailingaddress)
_______________________________________________________________________________________________________
streetno.streetnameapt.citystatezipcode
7.
DeliveryofGeneral(orSpecial)ElectionBallot(checkone) Delivertomeinpersonattheboardofelections
Iauthorize(givename):_______________________________________topickupmyballotattheboardofelections.
Mailballottomeat:(mailingaddress)
________________________________________________________________________________________________________
streetno.streetnameapt.citystatezipcode
ApplicantMustSignBelow
8.
IcertifythatIamaqualifiedandaregistered(andforprimary,enrolled)voter;andthattheinformationinthisapplicationis
trueandcorrectandthatthisapplicationwillbeacceptedforallpurposesastheequivalentofanaffidavitand,ifitcontainsa
materialfalsestatement,shallsubjectmetothesamepenaltiesasifIhadbeendulysworn.
SignHere:
X__________________________Date____/____/____
Ifapplicantisunabletosignbecauseofillness,physicaldisabilityorinabilitytoread,thefollowingstatement
mustbeexecuted:Bymymark,dulywitnessedhereunder,IherebystatethatIamunabletosignmyapplica
tionforanabsenteeballotwithoutassistancebecauseIamunabletowritebyreasonofmyillnessorphysical
disabilityorbecauseIamunabletoread.Ihavemade,orhavetheassistanceinmaking,mymarkinlieuof
mysignature.(Nopowerofattorneyorpreprintednamestampsallowed.Seedetailedinstructions.)
Date___/___/___NameofVoter:____________________________________Mark:___________________
I,theundersigned,herebycertifythattheabovenamedvoteraffixedhisorhermarktothisapplicationinmypres
enceandIknowhimorhertobethepersonwhoaffixedhisorhermarktosaidapplicationandunderstandthat
thisstatementwillbeacceptedforallpurposesastheequivalentofanaffidavitandifitcontainsamaterialfalse
statement,shallsubjectmetothesamepenaltiesasifIhadbeendulysworn.
_____________________________________________
_____________________________________________
(addressofwitnesstomark)
______________________________________
(signatureofwitnesstomark)
Board Use Only
2010 regular ab app2_rev (6/15/10)
Instructions:
Whomayapplyforanabsenteeballot?
Eachpersonmustapplyforthemselves.Itisafelonytomakeafalsestatementinanapplication
foranabsenteeballot,toattempttocastanillegalballot,ortohelpanyonetocastanillegalballot.
Informationformilitaryandoverseasvoters:
Ifyouareapplyingforanabsenteeballotbecauseyouoryourfamilyareinthemilitaryorbecause
youcurrentlyresideoverseas,donotusethisapplication.Youareentitledtospecialprovisionsif
youapplyusingtheFederalPostcardApplication.Formoreinformationaboutmilitary/overseas
voting,contactyourlocalboardofelectionsorrefertotheMilitaryandFederalVotingsectionsat:
http://www.elections.state.ny.us/Voting.html
Whereandwhentoreturnyourapplication:
Applicationsmustbemailedsevendaysbeforetheelection,orhanddeliveredtoyourcounty
boardofelectionsbythedaybeforetheelection.Iftheaddressofyourcountyboardofelections
isnotprovidedonthisform,contactinformationforyourlocalelectionofficecanbefoundonthe
NewYorkStateBoardofElectionswebsite,underCountyBoardsofElectiondirectoryat:
http://www.elections.state.ny.us/CountyBoards.html
Optionsavailabletoyouifyouhaveanillnessordisability:
Ifyouchecktheboxindicatingyourillnessordisabilityispermanent,onceyourapplicationisap
provedyouwillautomaticallyreceiveaballotforeachelectioninwhichyouareeligibletovote,
withouthavingtoapplyagain.Youmaysigntheabsenteeballotapplicationyourself,oryoumay
makeyourmarkandhaveyourmarkwitnessedinthespacesprovidedonthebottomoftheappli
cation.Pleasenotethatapowerofattorneyorprintednamestampisnotallowedforanyvoting
purpose.
Whenyourballotwillbesent:
Yourabsenteeballotmaterialswillbesenttoyouatleast32daysbeforefederal,state,county,city
ortownelectionsinwhichyouareeligibletovote.Ifyouappliedafterthisdate,yourballotwillbe
sentimmediatelyafteryourcompletedandsignedapplicationisreceivedandprocessedbyyour
localboardofelections.Ifyouprovidedatesinsection2,identifyingthetimeframewithinwhich
youwillbeabsentfromyourcountyorfromtheCityofNewYork,youwillbesentaballotforany
primary,general,specialelectionorpresidentialprimaryelectionwhichmightoccurduringthe
timeframeyouhavespecified.Ifyouprefer,youmaydesignatesomeonetopickupyourballotfor
you,bycompletingtherequiredinformationinsection6and/orsection7,asappropriate.Contact
yourlocalcountyboardofelectionsifyouhavenotreceivedyourballot.
BOROUGHOFFICESOFTHEBOARDOFELECTIONS
Manhattan,200VarickStreet,NewYork,N.Y.10014(212)8862100
Bronx,1780GrandConcourse,Bronx,N.Y.10457(718)9600730
Brooklyn,345AdamsStreet,Brooklyn,N.Y.11201(718)7978800
Queens,12606QueensBlvd.,KewGardens,N.Y.11415(718)7306730
StatenIsland,OneEdgewaterPlaza,StatenIsland,N.Y.10305(718)8760079