Request to be Placed on the Permanently Disabled Absentee List

First Name*
Last Name*
I, (First Name, Last Name), declare that I am a resident and registered voter of Cape Girardeau County, Missouri, and am permanently disabled. I hereby request that my name be placed on the election authority’s list of voters qualified to participate as absentee voters pursuant to section 115.284, and that I be delivered an absentee ballot application for each election in which I am eligible to vote.
Voter's Home Address*
City*
State*
Zip Code
Voter's Mailing Address
City
State
Zip Code
Date of Birth*
Last 4 Digits of Social Security #*
Home Telephone #*
Other Telephone #
Signature