Absentee Ballot Application Is True and Correct

A Pennsylvania Application for Absentee Ballot Page 1 07.2021

How to submit your application: Once your application is completed, you may return it to your local county board of elections. If you’re unsure of where to mail your application, please visit www.vote.pa.gov/County for more information. Deadline alert: The deadline to apply for a civilian absentee ballot is The deadline to return your completed ballot is 5:00PM on the Tuesday before the election. Please note 8:00PM on election day. Please note your completed your application must be received in the county board of ballot must be received by the county board of elec- election’s office by that time.Postmarks do not count. tion’s by that time. Postmarks do not count. Necessary identification: In order to apply for an absentee ballot, you must supply your PA Driver’s License or PennDOT issued photo ID card number in the Identification section. If you do not have a PA Driver’s License or PennDOT issued photo ID card, you must supply the last four (4) digits of your Social Security number.

If you do not have a valid form of either of these types of identification, please check the box titled “I do not have a PA driver’s license or a PennDOT ID card or a Social Security number” in the Identification section. If you choose this option, you must enclose a photocopy of an acceptable ID.

Please visit www.vote.pa.gov/MailBallot for more information, call 1-877-868-3772, or contact your county board of elections. What is an annual absentee ballot request? If you have a permanent illness or a permanent disability you may be added to the annual absentee request list. Once your physician signs the certification of permanent disability and your request is approved, you will automatically receive ballots for the remainder of the year, and you will receive an application to renew your request for absentee ballots each year.

If you update your voter registration due to relocation out of county after you submit an annual absentee ballot request, please ensure your annual status is transferred when updating your address.

Assistance in voting: If you require assistance with completing your ballot due to a disability, you must also complete a Statement of Absentee Elector Requiring Assistance form. Please visit www.vote.pa.gov for more information.

WARNING: If you receive an absentee ballot and return your voted ballot by the deadline, you may not vote at your polling place on election day. If you are unable to return your voted absentee ballot by the deadline, you may only vote a provisional ballot at your polling place on election day, unless you surrender your absentee ballot and the return envelope containing the Voter’s Declaration to the judge of elections to be voided to vote by regular ballot.

Questions?

Call your County For more information about Información en español: Election Office voting, visit our website: Si le interesa obtener este or call 1-877-868-3772. www.vote.pa.gov formulario en español, llame al 1-877-868-3772. A Pennsylvania Application for Absentee Ballot Page 1 07.2021

Print name First name Please print your name Middle name or initial exactly as registered. 1 Last name Jr Sr ll lll lV

About you Birth date (required) Phone number Phone & email are option- 2 al & used if information is missing on this form. Email

Your address Please print your Address (not P.O. Box) Apt. number address exactly as registered. If your address City State PA Zip County has changed, you should 3 first update your voter Voting district or registration. The deadline precinct (if known) Municipality Ward (if known) to update your address is 15 days before the date of the next election. I have lived at this address since Are you a State or Federal Government employee? Yes No

Where to mail Same as above Address or PO Box ballot? 4 City State Zip

This address is my (e.g. vacation home, temporary residence, etc.)

Identification If you have a PennDOT PA driver’s license or PennDOT ID card number number, you must use it. If not, please provide the last 5 Last four digits of your Social Security number X X X - X X - four digits of your Social Security number. See “Necessary Identification” instructions page. I do not have a PA driver’s license or a PennDOT ID card or a Social Security number.

Reason I hereby apply for an absentee ballot for the following reason: Select a reason for apply- 6 ing for an absentee ballot. I will be absent from my municipality (Complete section A) I have an illness or physical disability (Complete section B)

Section A – I declare that I am eligible to vote absentee at the forthcoming primary or election since I expect that my duties, occupation or business will require me to be absent from the municipality of my residence on the day of the primary or election for the Absence from reason stated below; and that all of the information which I have listed on this absentee ballot application is true and correct. municipality A Reason for absence

Voter signature here X Date

Section B – I declare that I am eligible to vote absentee at the forthcoming primary or election due to the illness or physical disability Illness/ stated below; that the information required to be listed pertaining to my attending physician is correctly stated herein; and that all other information which I have listed on this absentee ballot application is true and correct. Physical disability Nature of illness or physical disability B1 Physician name Physician phone

Physician office address

Voter signature here X Date

Help with this I hereby state that I am unable to sign my application for an absentee ballot without assistance because I am unable to write by reason of my illness or physical disability. I have made, or have received assistance in making my mark in lieu of my signature. form Complete this section Mark of voter X Date if you are unable to B2 sign in Section B1 because of illness or Address of witness physical disability. See “Assistance in voting”. Signature of witness X

Section C (Optional): Annual Absentee Ballot Request Because of Permanent Illness or Permanent Disability and Physician’s Certification (to be completed with your Physician below)

• If you are a voter with a permanent illness or a permanent disability, you may request to be placed on an annual absentee ballot list. See “What is an annual absentee ballot request?” on Page 3.

• You need only file a physician’s certificate of permanent illness or permanent disability once. Once your disability status has been certified by your physician, your physician will not need to recertify your disability status, and you will be placed on the annual absentee voter list.

• If you are approved as an annual absentee voter, you will recieve an application to renew your request for absentee ballots each year.

• If you lose your disability status, you must inform your county board of elections.

• If you update your voter registration due to relocation out of county after you submit an annual absentee ballot request, please ensure your annual status is transferred when updating your address.

Annual If you would like to receive absentee ballots for the remainder of this year and if you would like to automatically receive an annual application to automatically receive absentee ballots each year, please indicate below. If you update your voter absentee registration due to relocation out of county after you submit an annual absentee ballot request, please ensure your annual status is request transferred when updating your address. See “What is an C1 annual absentee ballot request?” for more  I would like to receive absentee ballots this year and receive annual applications for absentee ballots each year. information. (Please have your physician sign the certification in Section C2.)

Certificate of I hereby certify that the above named voter is permanently disabled, and either physically unable to attend the polls or permanent physically unable both to operate a voting machine (or mark the ballot) and to orally request assistance to do so. illness or permanent Signature of physician X physical C2 disability Print physician name Have your physician sign this certification if you indicated you would like to be an Date annual absentee voter in section C1.

Adams Chester Fulton Mercer Susquehanna 117 Baltimore St 601 Westtown Rd 116 W Market St 5 Courthouse PO Box 218 Rm 106 Ste 150 Ste 205 Mercer PA 16137-1227 31 Lake Ave Gettysburg PA 17325 PO Box 2747 McConnellsburg PA 17233 (724) 662-7542 Montrose PA 18801 (717) 337-9832 West Chester PA 19380-0990 (717) 485-6872 (570) 278-6697 (610) 344-6410 Mifflin Allegheny Greene 20 N Wayne St Tioga 542 Forbes Ave Clarion 93 E High St Lewistown PA 17044 118 Main St Ste 609 Administrative Building Rm 102 (717) 248-6571 Wellsboro PA 16901 Pittsburgh PA 15219-2913 330 Main St Waynesburg PA 15370 (570) 723-8230 (412) 350-4500 Rm 104 (724) 852-5230 Monroe Clarion PA 16214 One Quaker Plaza Union Armstrong (814) 226-4000 Ext 2006 Huntingdon Rm 105 155 N 15th St Administration Bldg Bailey Building Stroudsburg PA 18360 Lewisburg PA 17837-8822 450 E Market St Clearfield 233 Penn St (570) 517-3165 (570) 524-8681 Ste 207 212 E Locust St Huntingdon PA 16652-1486 Kittanning PA 16201 Ste 106 (814) 643-3091 Ext 205 Montgomery Venango (724) 548-3222 Clearfield PA 16830 Voter Services 1174 Elk St (814) 765-2642 ext 5053 Indiana PO Box 311 PO Box 831 Beaver 825 Philadelphia St Norristown PA 19404-0311 Franklin PA 16323-0831 810 Third St Clinton Indiana PA 15701-3934 (610) 278-3280 (814) 432-9514 Beaver PA 15009 2 Piper Way (724) 465-3852 (724) 770-4440 Ste 309 Montour Warren Lock Haven PA 17745 Jefferson 253 Mill St 204 4th Ave Bedford (570) 893-4019 155 Main St Danville PA 17821 Warren PA 16365 200 S Juliana St Jefferson Place (570) 271-3002 (814) 728-3406 3rd Fl Columbia Brookville PA 15825-1269 Ste 301 PO Box 380 (814) 849-1693 Northampton Washington Bedford PA 15522 Bloomsburg PA 17815-0380 Elections Division 100 W Beau St (814) 623-4807 (570) 389-5640 Juniata 669 Washington St Rm 206 1 N Main St Easton PA 18042 Washington PA 15301 Berks Crawford PO Box 68 (610) 829-6260 (724) 228-6750 633 Court St 903 Diamond Park Mifflintown PA 17059 1st Fl Meadville PA 16335 (717) 436-7706 Northumberland Wayne Reading PA 19601 (814) 333-7307 320 N 2nd St 925 Court St (610) 478-6490 Lackawanna Ste 1 Honesdale PA 18431 Cumberland 123 Wyoming Ave Sunbury PA 17801 (570) 253-5978 Blair 1601 Ritner Highway 2nd Floor (570) 988-4208 279A Loop Road Ste 201 Scranton PA 18503 Westmoreland Hollidaysburg PA 16648 Carlisle PA 17013 (570) 963-6737 Perry 2 N Main St (814) 693-3287 (717) 240-6385 PO Box 37 Ste 109 Lancaster New Bloomfield PA 17068 Greensburg PA 15601 Bradford Dauphin PO Box 2139 (717) 582-2131 ext 4110 (724) 830-3150 6 Court St PO Box 1295 Lancaster PA 17608 Ste 2 Harrisburg PA 17108-1295 (717) 299-8293 Philadelphia Wyoming Towanda PA 18848 (717) 780-6360 City Hall, Room 142 1 Courthouse Sq (570) 265-1717 Lawrence 1400 John F Kennedy Blvd Tunkhannock PA 18657 Delaware 430 Court St Philadelphia, PA 19107 (570) 996-2226 Bucks Govt Center Bldg New Castle PA 16101 (215) 686-3469 55 E Court St 201 W Front St (724) 656-2161 York Doylestown PA 18901-4318 Media PA 19063-2728 Pike 28 E Market St (215) 348-6163 (610) 891-4659 Lebanon 506 Broad St York PA 17401-1579 400 S 8th St Milford PA 18337 (717) 771-9604 Butler Elk Municipal Bldg (570) 296-3427 PO Box 1208 300 Center St Rm 209 Butler PA 16003 PO Box 448 Lebanon PA 17042 Potter 1 N Main St (724) 284-5308 Ridgway PA 15853-0448 (717) 228-4428 For a listing of available (814)776-5337 Ste 204 Cambria Lehigh Coudersport PA 16915 email addresses, go to 200 S Center St Erie 17 S 7th St (814) 274-8467 www.vote.pa.gov/county. Ebensburg PA 15931 140 W 6th St Allentown PA 18101-2401 (814) 472-1464 Rm 112 (610) 782-3194 Schuylkill Erie PA 16501 420 N Centre St Cameron (814) 451-6276 Luzerne Pottsville PA 17901 20 E Fifth St 20 N Pennsylvania Ave (570) 628-1467 Emporium PA 15834-1469 Fayette Ste 207 (814) 486-9321 22 E Main St Wilkes-Barre PA 18701 Snyder Public Service Bldg (570) 825-1715 PO Box 217 Carbon Uniontown PA 15401 Middleburg PA 17842-0217 410 Center Ave (724) 430-1289 Lycoming (570) 837-4207 Jim Thorpe PA 18229-0170 48 W Third St (570) 325-4801 Forest Williamsport PA 17701-9536 Somerset 526 Elm St (570) 327-2267 300 N Center Ave Centre Box 3 Ste 340 420 Holmes St Tionesta PA 16353 McKean Somerset PA 15501 Willowbank Office Bldg (814) 755-3537 500 W Main St (814) 445-1549 Bellefonte PA 16823-1486 Smethport PA 16749 (814) 355-6703 Franklin (814) 887-3203 Sullivan 157 Lincoln Way East 245 Muncy St Chambersburg PA 17201-2211 PO Box 157 (717) 261-3886 Laporte PA 18626 (570) 946-5201 ext 7