Absentee Ballot Application
DUTCHESS COUNTY BOARD OF ELECTIONS
ABSENTEE BALLOT APPLICATrON
MAIL TO: BOARD OF ELECTIONS
DUTCHESS COUNTY
47 CANNON STREET
POUGHKEEPSIE, NY 12601
Te/.No. (845) 48t5-2473
ADDRESS IN DUTCHESS COUNTY
NAME
ADDRESS
CITY ZIP CODE
DATE OF BIRTH
I am a registered voter in Dutchess Count)' and do now apply for an
Absentee Ballot for the, CJ General Election, CJ Primary Election.
I know of no reason why I am no longer qualified to vote.
SEND BALLOT TO:
ZIP CODE
FOR OFFICE USE ONLY
REG. NUMBER
TOWN/CITY
WARD DISTRICT
Congo C.L.D
A.D PARTY
VOTED IN OFFICE [J
BALLOT TAKEN Cl
I will be absent from Dutchess County on the day of election for one of the following reasons:
P\..EASE CHECK THE BOX FOR THE APPROPRIATE REASON AND COMPLETE THESTA TEMENT TO THE RIGHT
[J 1.BUSINESS MUST BE COMPLETE ~
[J 2.VACATION o......E:;t
[J
[J
Dates you intend to be out of Dutchess County:
From To
Please state where you will be on Election Day.
3.EDUCA TION (SCHOOL OUTSIDE DUTCHESS COUNTY)
4.1 WILL BE DETAINED IN .JAIL FOR AN OFFENSE
OTHER THAN FELONY OR AWAITING TRIAL OR
GRAND JURY ACTION. (PRINT NAME OF INSTITUTION)
[J 5.ILLNESS OR PHYSICAL DISABILITY (STATEMENT BELOW MUST BE COMPLETE)
I certify that I have been advised by my medical or christian science practitioner, (Give name and address)
that I will be unable to appear
personally at the polling place of the district in whicb I am registered on election day for tbe reason indicated below.
Nature of your illness or disability CJ PERMANENT, CJ TEMPORARY
I will be confined, C At Home, CJ In a Hospital (Give name and address) ,
Special Notice: Power of Attorney or use of signature stamp is not acceptable. Signature must be a signature or voter's mark.
ALL APPLICANTS MUST FILL OUT THE FOLLOWING:
I certify that the iQformation in this application will be accepted for all purposes as the equivalent of an affidavit and,
if it contains a material false statement, shall subject me to the same penalties as if I ha~ been duly sworn.
DATE
SIGNATURE OF VOTER
If applicant is unable to sign the application because of illness or physical disability the following statement must be completed. By
my mark, du1y witnessed hereunder, I state that r am unable to write because of my illness, physical disability or I can not read. I
have made or have received assistance in making my mark in lieu of my signature.
DATE
MARK OF VOTER
I certify that the above named voter\ affixed his mark to this application in my presence and I know him/her to be the person who
affixed his/her mark to the application and understand tha:! this statement will be accepted for all purposes as the equivalent of an
affidavit and, if it contains a false statement, shall subject me to the same penalties as if I had been duly sworn. .
SIGNATURE OF WITNESS TO MARK
This application must be postmarked at least seven (7) days before election.
In person application and voting up to 5 P.M. day before election.
DATE