application for ballot by mail - dallas county · 2020. 4. 8. · 2. residence address: see back of...
TRANSCRIPT
DO NOT REMOVE PERFORATED TABS. Moisten here and fold bottom to top to seal. DO NOT REMOVE PERFORATED TABS. Moisten here and fold bottom to top to seal.
Application for Ballot by Mail Prescribed by the Office of the Secretary of State of Texas A5-15 12/17
For Official Use OnlyVUID #, County Election Precinct #, Statement of Residence, etc.
1 Last Name (Please print information) Suffix (Jr., Sr., III, etc) First Name Middle Initial
2 Residence Address: See back of this application for instructions. City ,TX ZIP Code
3 Mail my ballot to: If mailing address differs from residence address, please complete Box # 7. City State ZIP Code
4 Date of Birth (mm/dd/yyyy) (Optional) Contact Information (Optional)*Please list phone number and/or email address:* Used in case our office has questions.
5 Reason for Voting by Mail:65 years of age or older. (Complete Box #6a)
Disability. (Complete Box #6a)
Expected absence from the county. (Complete Box #6b and Box #8)You will receive a ballot for the upcoming election only
Confinement in jail. (Complete Box #6b) You will receive a ballot for the upcoming election only
6a ONLY Voters 65 Years of Age or Older or Voters with a Disability:If applying for one election, select appropriate box. If applying once for elections in the calendar year, select “Annual Application.”
Annual Application
Uniform and Other Elections:
May Election
November Election
Other ___
Primary Elections:You must declare one political party to vote in a primary:
Democratic Primary
Republican Primary
Any Resulting Runoff
6b ONLY Voters Absent from County or Voters Confined in Jail:You may only apply for a ballot by mail for one election, and any resulting runoff.Please select the appropriate box.
Uniform and Other Elections:
May Election
November Election
Other ____
Primary Elections:You must declare one political party to vote in a primary:
Democratic Primary
Republican Primary
Any Resulting Runoff
7 If you are requesting this ballot be mailed to a different address (other than residence), indicate where the ballot will be mailed. See reverse for instructions.
Mailing Address as listed on my voter registration certificate
Nursing home, assisted living facility, or long term care facility
Hospital
Retirement Center
Address of the jail
Relative; relationship _____
Address outside the county (see Box #8)
8 If you selected “expected absence from the county,” see reverse for instructions
Date you can begin to receive mail at this address Date of return to residence address
9 Voters may submit a completed, signed, and scanned application to the Early Voting Clerk at:
(early voting clerk’s e-mail address ) (early voting clerk’s fax)
NOTE: If you fax or e-mail this form, please be aware that you must also mail the form to the early voting clerk within four business days. See “Submitting Application” on the back of this form for additional information.
10 “I certify that the information given in this application is true, and I understand that giving false information in this application is a crime.”
X Date
SIGN HEREIf applicant is unable to sign or make a mark in the presence of a witness, the witness shall complete Box #11.
If someone helped you to complete this form or mails the form for you, then that person must complete the sections below.
11 See back for Witness and Assistant definitions. If applicant is unable to mark Box #10 and you are acting as a Witness to that fact, please check this box and sign below.
If you assisted the applicant in completing this application in the applicant’s presence or e-mailed/mailed or faxed the application on behalf of the applicant, please check this box as an Assistant and sign below.
*If you are acting as Witness and Assistant, please check both boxes. Failure to complete this information is a Class A misdemeanor if signature was witnessed or applicant was assisted in completing the application.
XSignature of Witness /Assistant
XPrinted Name of Witness/Assistant
Street Address Apt Number (if applicable) City
State ZIP Code
Witness’ Relationship to Applicant(Refer to Instructions on back for clarification)
Este formulario está disponible en Español. Para conseguir la version en Español favor de llamar sin cargo al 1.800.252.8683 a la oficina del Secretario de Estado o la Secretaria de Votación por Adelantado.
_________________________________________________________ ___________________________________
AFFIX LABEL HERE OR ADDRESSTO: EARLY VOTING CLERK
DO NOT REMOVE PERFORATED TABS. Moisten tab and fold top to bottom to seal.
AFFIX FIRST CLASS
POSTAGEFROM: _________________________________
_________________________________
_________________________________
Inst
ruct
ions
for A
pplic
atio
n fo
r Bal
lot b
y M
ail
Res
iden
ce A
ddre
ss -
Giv
e fu
ll ad
dres
s as
sho
wn
on y
our v
oter
regi
stra
tion
certi
ficat
e. If
you
ha
ve m
oved
with
in th
e co
unty
but
not
yet
cha
nged
you
r vot
er re
gist
ratio
n ad
dres
s w
ith th
e vo
ter
regi
stra
r, in
dica
te y
our n
ew re
side
nce
addr
ess.
Mai
l Bal
lot T
o - G
ive
full a
ddre
ss w
here
you
wis
h to
hav
e ba
llot m
aile
d, if
the
addr
ess
is d
iffer
ent
from
you
r res
iden
ce a
ddre
ss.
Mai
ling
Bal
lot t
o a
Diff
eren
t Add
ress
- Yo
ur b
allo
t mus
t be
mai
led
to y
our h
ome
whe
re y
ou liv
e or
to y
our m
ailin
g ad
dres
s on
you
r vot
er re
gist
ratio
n ce
rtific
ate.
The
re a
re s
ome
exce
ptio
ns th
at
allo
w y
ou to
hav
e yo
ur b
allo
t mai
led
to a
diff
eren
t loc
atio
n as
spe
cifie
d be
low.
Rea
son
for v
otin
g by
mai
l Lo
catio
n to
mai
l bal
lot
65 o
r dis
able
d N
ursi
ng h
ome,
ass
iste
d liv
ing/
retir
emen
t cen
ter,
rela
tive,
ho
spita
l In
jail
Add
ress
of j
ail o
r rel
ativ
e A
bsen
t fro
m c
ount
y A
ddre
ss lo
cate
d ou
tsid
e of
cou
nty
Expe
cted
Abs
ence
from
Cou
nty
- If y
ou c
hose
exp
ecte
d ab
senc
e fro
m c
ount
y, y
ou m
ust e
xpec
t to
be
abse
nt fr
om th
e co
unty
on
elec
tion
day
and
durin
g th
e ho
urs
of e
arly
vot
ing
in p
erso
n or
fo
r the
rem
aind
er o
f the
ear
ly v
otin
g pe
riod
afte
r you
sub
mit
your
app
licat
ion.
You
r bal
lot m
ust
be m
aile
d to
an
addr
ess
outs
ide
the
coun
ty. I
mpo
rtant
: Giv
e da
te y
ou c
an b
egin
to re
ceiv
e m
ail a
t the
add
ress
giv
en.
Ann
ual A
pplic
atio
n - I
f you
are
65
year
s of
age
or o
lder
, or d
isab
led
you
may
app
ly to
rece
ive
all
ballo
ts b
y m
ail f
or a
cal
enda
r yea
r. If
you
do n
ot s
elec
t any
ele
ctio
ns in
Box
6a,
you
r app
licat
ion
will
be c
onsi
dere
d an
Ann
ual A
pplic
atio
n. If
you
sub
mit
an a
nnua
l app
licat
ion
for a
bal
lot b
y m
ail,
your
app
licat
ion
may
be
forw
arde
d to
oth
er e
ntiti
es h
oldi
ng e
lect
ions
whe
re y
ou a
re a
qua
lified
vo
ter.
This
mea
ns th
at y
ou m
ay re
ceiv
e a
ballo
t for
thos
e el
ectio
ns in
add
ition
to th
e ba
llot(s
) yo
u re
ques
ted
with
this
app
licat
ion.
Subm
ittin
g A
pplic
atio
n1.
Sig
n an
d da
te y
our a
pplic
atio
n - I
f una
ble
to s
ign,
ple
ase
go to
Witn
ess/
Addr
ess
boxe
s (1
1 on
reve
rse)
and
hav
e a
pers
on w
itnes
s yo
ur m
ark.
Witn
ess/
Assi
stan
t ins
truct
ions
follo
w b
elow
.
2. D
eliv
er to
Ear
ly V
otin
g C
lerk
- Yo
u m
ay s
ubm
it yo
ur a
pplic
atio
n vi
a th
ese
met
hods
:
In P
erso
n: O
nly
the
appl
ican
t may
sub
mit
thei
r app
licat
ion
in p
erso
n to
the
Early
Vot
ing
Cle
rk
until
the
early
vot
ing
perio
d be
gins
. How
ever
, afte
r the
ear
ly v
otin
g pe
riod
begi
ns fo
r an
elec
tion,
th
e ap
plic
ant m
ay o
nly
subm
it th
eir a
pplic
atio
n vi
a m
ail,
com
mon
con
tract
car
rier,
fax,
or e
-mai
l.
By M
ail:
You
may
mai
l you
r app
licat
ion
via
the
U.S
. Pos
tal S
ervi
ce.
By C
omm
on C
ontra
ct C
arrie
r: Yo
u m
ay s
ubm
it vi
a a
com
mon
or c
ontra
ct c
arrie
r whi
ch is
a b
ona
fide,
for p
rofit
car
rier.
By F
ax: Y
ou m
ay fa
x yo
ur a
pplic
atio
n to
the
Early
Vot
ing
Cle
rk. P
leas
e co
ntac
t you
r Ear
ly V
otin
g C
lerk
or t
he S
ecre
tary
of S
tate
’s O
ffice
for f
ax n
umbe
rs.
By E
-Mai
l: Yo
u m
ay e
-mai
l a s
igne
d, s
cann
ed im
age
of y
our a
pplic
atio
n to
the
Early
Vot
ing
Cle
rk.
Plea
se c
onta
ct y
our E
arly
Vot
ing
Cle
rk o
r the
Sec
reta
ry o
f Sta
te’s
Offi
ce fo
r e-m
ail a
ddre
sses
.IF
YO
U F
AX
OR
E-M
AIL
YO
UR
APP
LIC
ATIO
N T
O T
HE
EAR
LY V
OTI
NG
CLE
RK
, YO
U M
UST
A
LSO
MA
IL T
HE
APP
LIC
ATI
ON
SO
TH
AT
THE
CLE
RK
REC
EIVE
S IT
NO
LA
TER
TH
AN
TH
E FO
UR
TH B
USI
NES
S D
AY
AFT
ER T
HE
DA
Y TH
E C
LER
K R
ECEI
VED
YO
UR
FA
XED
OR
EM
AIL
ED A
PPLI
CA
TIO
N.
If
you
fax
or e
-mai
l yo
ur a
pplic
atio
n by
the
de
adlin
e no
ted
belo
w, y
our a
pplic
atio
n w
ill b
e co
nsid
ered
com
plet
e an
d tim
ely
as lo
ng a
s th
e or
igin
al is
rece
ived
by
the
early
vot
ing
cler
k by
the
four
th b
usin
ess
day
afte
r it
was
su
bmitt
ed b
y fa
x or
e-m
ail.
Dea
dlin
eYo
ur a
pplic
atio
n m
ust b
e re
ceiv
ed b
y th
e ea
rly v
otin
g cl
erk
of th
e lo
cal e
ntity
con
duct
ing
the
elec
tion
not l
ater
than
the
11th
day
bef
ore
elec
tion
day.
If th
e 11
th d
ay is
a w
eeke
nd o
r hol
iday
, th
e de
adlin
e is
the
first
pre
cedi
ng b
usin
ess
day.
You
may
sub
mit
an a
pplic
atio
n th
roug
hout
the
cale
ndar
yea
r, be
ginn
ing
Janu
ary
1. P
leas
e re
mem
ber t
hat t
he a
pplic
atio
n m
ust b
e re
ceiv
ed n
ot
late
r tha
n th
e 11
th d
ay b
efor
e th
e fir
st e
lect
ion
in w
hich
you
see
k to
vot
e by
mai
l.
If yo
u su
bmit
an A
nnua
l App
licat
ion
for B
allo
t by
Mai
l with
in 6
0 da
ys b
efor
e an
ele
ctio
n th
at ta
kes
plac
e in
the
follo
win
g ca
lend
ar y
ear,
your
app
licat
ion
will
be v
alid
for a
ny e
lect
ion
that
take
s pl
ace
in th
e fo
llow
ing
cale
ndar
yea
r, re
gard
less
of t
he fa
ct th
at y
our a
pplic
atio
n w
as s
ubm
itted
prio
r to
the
end
of th
e pr
eced
ing
cale
ndar
yea
r. Th
is a
pplie
s to
Ann
ual A
pplic
atio
ns o
nly
and
not t
o a
regu
lar a
pplic
atio
n fo
r bal
lot b
y m
ail.
Witn
ess/
Ass
ista
nt S
ectio
nW
itnes
s: If
you
are
una
ble
to s
ign
your
nam
e (d
ue t
o a
phys
ical
dis
abilit
y or
illit
erac
y),
the
appl
icat
ion
may
be
sign
ed a
t Box
#11
for
you
by a
Witn
ess.
You
mus
t affi
x yo
ur m
ark
to th
e ap
plic
atio
n in
Box
#10
or,
if yo
u ar
e un
able
to m
ake
a m
ark,
then
the
Witn
ess
mus
t che
ck th
e ap
prop
riate
box
in 1
1 in
dica
ting
the
inab
ility
to m
ake
a m
ark.
The
Witn
ess
mus
t sta
te h
is/h
er
nam
e in
prin
ted
form
and
indi
cate
his
/her
rel
atio
nshi
p to
you
or,
if un
rela
ted,
sta
te th
at fa
ct.
The
Witn
ess
mus
t sig
n an
d pr
ovid
e hi
s or
her
prin
ted
nam
e an
d re
side
nce
addr
ess.
Unl
ess
the
Witn
ess
is a
clo
se re
lativ
e of
the
vote
r (pa
rent
, gra
ndpa
rent
, spo
use,
chi
ld o
r sib
ling)
, it i
s a
Cla
ss
B m
isde
mea
nor f
or a
per
son
to w
itnes
s m
ore
than
one
app
licat
ion
for b
allo
t by
mai
l.
Ass
ista
nt:
If a
pers
on (
othe
r th
an a
clo
se r
elat
ive
or p
erso
n re
gist
ered
to v
ote
at th
e sa
me
addr
ess)
ass
ists
you
in c
ompl
etin
g th
is a
pplic
atio
n in
you
r pre
senc
e or
mai
ls/fa
xes/
e-m
ails
this
ap
plic
atio
n on
you
r beh
alf,
then
that
per
son
mus
t com
plet
e Bo
x #1
1. T
he A
ssis
tant
mus
t sig
n,
prov
ide
his
or h
er p
rinte
d na
me,
and
his
or h
er re
side
nce
addr
ess.
A p
erso
n co
mm
its a
Cla
ss
A m
isde
mea
nor i
f the
per
son
prov
ides
ass
ista
nce
with
out p
rovi
ding
the
info
rmat
ion
desc
ribed
ab
ove
unle
ss a
clo
se re
lativ
e or
regi
ster
ed a
t you
r add
ress
.
If yo
u ha
ve fu
rthe
r que
stio
ns o
r nee
d ad
ditio
nal a
ssis
tanc
e, p
leas
e co
ntac
t yo
ur E
arly
Vot
ing
Cle
rk o
r The
Sec
reta
ry o
f Sta
te’s
offi
ce a
t 1-8
00-2
52-8
683
or w
ww
.sos
.sta
te.tx
.us.