Board of Election Commissioners, Clay County, MO

ABSENTEE BALLOT APPLICATION REQUEST FORM

To request an absentee ballot from Clay County, Missouri Election Board print this page.

1. Complete all blanks below on the Absentee Ballot Request Form.
2. Print and Sign request - Signature must be the voter's.
3. Mail to: Absentee Department, Clay County Board of Elections, 100 W. Mississippi St., Liberty, Missouri 64068-1623 or Fax to: (816)792-5334.

FOR OFFICE USE ONLY

Precinct:____________________

ID Number:______________

Initials:__________________

I, for the purpose of securing an absentee ballot for the election to be held on hereby declare that I am a registered voter at the following address:
, Clay County, Missouri; that I am lawfully entitled to vote an absentee ballot at said election; that the reason for requesting an absentee ballot is, Please check ONE:

	Absence on Election Day from the jurisdiction of the election authority in which I am registered;
	Incapacity or confinement due to illness or physical disability; including caring for a person who is incapacitated or confined due to illness or disability;
	Religious Belief or Practice;
	Employment as an election authority or by an election authority at a location other than my polling place;
	Incarceration, although I retained all the necessary qualifications for voting;

I hereby declare under the penalties of perjury that the foregoing reason is true and correct, and that I truly expect to be prevented from going to the polls on election day due to the cause checked above.

___________________________________________
(Signature of Voter)	(Date of Birth)	(Last 4 digits of SSN)

PENALTY FOR VIOLATION - If any person shall willfully make any false certification, affidavit or statement required to be made under Missouri Election Laws, such person, upon conviction thereof, shall be deemed guilty of a class one election offense.

Mail Ballot To: (if different than above)

(Number/Street or Road)

(City)	(State)	(Zip)

*If this request is for a PRIMARY ELECTION you must choose a party ballot in order to vote on candidates and races or the ballot you receive will be considered non partisan and will not include candidate�s names only issues if there are any.

**This application if signed by the voter personally may be mailed to the Board, if received by the Board no later than 5:00 PM on the Wednesday prior to the election. No application may be delivered by messenger. Application made by a guardian or relative must be made in person at the Board Office.