Request for Absentee Ballot

First Name*

Last Name*

Election Date - Name*

Date of Birth*

Last 4 Digits of SSN*

Please indicate the name of the Political Party ballot you wish to receive (for Primary Elections only):

I, (First Name, Last Name), do hereby request an absentee ballot for the November 2, 2021 Special Election

Reason for requesting an absentee ballot*

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 judge at a location other than my polling place
Incareration, although I have retained all the necessary qualifications for voting
Certified participation in the address confidentiality program established under sections 589.660 to 589.681 because of safety concerns

My home address where I am registered to vote in Cape Girardeau County is:

Street Address*

City*

State*

Zip Code*

Address where ballot is to be mailed:*

City*

State*

Zip Code*

Phone Number*

Email Address

Signature

I do solemnly swear that all statements made on this application are true to the best of my knowledge and belief.

The deadline to submit this request to have an absentee ballot mailed to you is 5:00 p.m. on the 2nd Wednesday prior to the election. The deadline for absentee voting in person in the office is 5:00 p.m. on the day before the election. For questions contact the County Clerk’s Office: (573)243-3547.

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