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Absentee Ballot Request Form

If you are a registered voter or near relative, please complete the form below. Please print the form that appears after you submit your data.

Required fields are labeled green.

Requester Information

Date:
Voter's Last Name:
Voter's First Name:
Voter's Middle or Maiden Name:
Voter's Date of Birth (MM/DD/YYYY):
Street Address 1:
Street Address 2:
City:
State:
Zip:
Phone:
Email:
Requester: Self
Relative (fill fields below)

Mailing Address for Absentee Ballot

Mailing Address:

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