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NewYorkStateAbsenteeBallotApplication BOARD USE ONLY:

Pleaseprintclearly.Seedetailedinstructions.

Town/City/Ward/Dist:

Thisapplicationmusteitherbepersonallydeliveredtoyourcountyboardofelectionsnot
laterthanthedaybeforetheelection,orpostmarkedbyagovernmentalpostalservice
notlaterthan7thdaybeforeelectionday.Theballotitselfmusteitherbepersonally
deliveredtotheboardofelectionsnolaterthanthecloseofpollsonelectionday,or
postmarkedbyagovernmentalpostalservicenotlaterthanthedaybeforetheelectionand
receivednolaterthanthe7thdayaftertheelection.

Registration No: ____________________

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