Office of the Kansas Secretary of State Application for Advance Ballot by Mail FORM DOWNLOAD THIS FORM AT WWW.SOS.KS.GOV AV1M

1. Affirmation

Affirmation of an Elector of the County of ______and State of Kansas Desiring to Vote an Advance Voting Ballot State of ______, County of ______, ss: (where application is completed)

2. Voter Identification Requirements

I understand that my current and valid Kansas driver’s license number or Kansas nondriver’s identification card number must be provided in order to receive a ballot.

Current Kansas driver’s license number or nondriver’s identification card number: ______

If I do not have a current and valid Kansas driver’s license number or Kansas nondriver’s identification card number, I must provide a copy of one of the following forms of photo identification with this application in order to receive a ballot.

• Driver’s license issued by Kansas or another state • U.S. military ID • Nondriver’s ID card issued by Kansas or another state • Student ID card issued by an accredited Kansas postsecondary • U.S. passport educational institution • Concealed carry of handgun license issued by Kansas • Public assistance ID card issued by a government office or another state • ID card issued by an Indian tribe • Employee badge or ID document issued by a government office

3. Personal Information Please print.

______Last Name First Name M.I. Date of Birth (MM/DD/YY) ______Residential Address City State Zip Code Political Party (To be filled in only when requesting a primary election ballot): □ Democratic □ Republican

4. Address to Mail Ballot (if different from residential address)

______Mailing Address City State Zip Code

Note: The ballot may be mailed only to the voter’s residential or mailing address as indicated on the county voter registration list, to the voter’s temporary residential address, or to a medical care facility where the voter resides. These restrictions do not apply to a voter who has an illness, disability or who lacks proficiency in the English language. Ballots cannot be mailed until 20 days before the election.

5. Voter Signature Note: False statement on this affirmation is a severity level 9, nonperson felony.

I do solemnly affirm under penalty of perjury that I am a qualified elector residing at the address listed above, or I am authorized to sign for the above named voter who has a disability preventing the voter from signing an application. I am entitled to vote an advance voting ballot and I have not voted and will not otherwise vote at the election to be held on ______(date).

Required ______Signature of Voter Date (MM/DD/YY) Phone Number

FOR OFFICE USE ONLY Date App. Rec’d. ______Ballot Mailed ______Transmitted by ______

Prepared by the Office of the Secretary of State, 1st Floor, Memorial Hall, 120 S.W. 10th Avenue, Topeka, KS 66612-1594. KSA 25-1122d(a). Rev 10/22/20 tc Allen County Anderson County Atchison County Barber County Barton County Bourbon County Brown County 1 N Washington 100 E 4th 423 N 5th 120 E Washington Room 202, 1400 Main St. 210 S National 601 Oregon St Iola, KS 66749 Garnett, KS 66032 Atchison, KS 66002-1861 Medicine Lodge, KS 67104 Great Bend, KS 67530 Ft Scott, KS 66701 Hiawatha, KS 66434 Phone: (620) 365-1407 Phone: (785) 448-6841 Phone: (913) 367-1653 Phone: (620) 886-3961 Phone: (620) 793-1835 Phone: (620) 223-3800 Phone: (785) 742-2581 Fax: (620) 365-1441 Fax: (785) 448-3205 Fax: (913) 367-0227 Fax: (620) 886-5425 Fax: (620) 793-1990 Fax: (620) 223-5832 Fax: (785) 742-7705

Butler County Chase County Chautauqua County Cherokee County Cheyenne County Clark County Clay County 205 W Central Courthouse PO Box 529 215 N Chautauqua PO Box 14, 110 W Maple PO Box 985, 212 E PO Box 886, 913 Highland 712 5th St., Suite 102 El Dorado, KS 67042 Cottonwood Falls, KS Sedan, KS 67361 Columbus, KS 66725 Washington Ashland, KS 67831 Clay Center, KS 67432 Phone: (316) 322-4233 66845-0547 Phone: (620) 725-5800 Phone: (620) 429-2042 St Francis, KS 67756 Phone: (620) 635-2813 Phone: (785) 632-2552 Fax: (316) 321-1011 Phone: (620) 273-6423 Fax: (620) 725-5801 Fax: (620) 429-1042 Phone: (785) 332-8800 Fax: (620) 635-2051 Fax: (785) 632-5856 Fax: (620) 273-6617 Fax: (785) 332-8825

Cloud County Coffey County Comanche County Cowley County Crawford County Decatur County Dickinson County 811 Washington Room 202, 110 S 6th Box 776, 201 S New York 321 E 10th Avenue PO Box 249, 111 E Forest PO Box 28 PO Box 248, 109 E 1st, Concordia, KS 66901 Burlington, KS 66839 Coldwater, KS 67029 Winfield, KS 67156 Girard, KS 66743-0249 Oberlin, KS 67749 Ste. 207 Phone: (785) 243-8110 Phone: (620) 364-2191 Phone: (620) 582-2361 Phone: (620) 221-5495 Phone: (620) 724-6115 Phone: (785) 475-8102 Abilene, KS 67410 Fax: (785) 243-8123 Fax: (620)-265-0022 Fax: (620) 582-2426 Fax: (620) 221-5498 Fax: (620) 724-6007 Fax: (785) 475-8150 Phone: (785) 263-3774 Fax: (785) 263-2045

Doniphan County Douglas County Edwards County Elk County Ellis County Ellsworth County Finney County PO Box 278 1100 Massachusetts St 312 Massachusetts PO Box 606, 127 N Pine PO Box 720 210 N Kansas Finney Co. Admin. Center Troy, KS 66087 Lawrence, KS 66044 Kinsley, KS 67547 Howard, KS 67349 Hays, KS 67601 Ellsworth, KS 67439 311 N. 9th St., P.O. Box M Phone: (785) 985-3513 Phone: (785) 832-5281 Phone: (620) 659-3000 Phone: (620) 374-2490 Phone: (785) 628-9410 Phone: (785) 472-4161 Garden City, KS 67846 Fax: (785) 985-3723 Fax: (785) 832-5192 Fax: (620) 659-2583 Fax: (620) 374-2771 Fax: (785) 628-9413 Fax: (785) 472-3818 Phone: (620) 272-3500 Fax: (620) 272-3890

Ford County Franklin County Geary County Gove County Graham County Grant County Gray County 100 Gunsmoke 315 S Main 200 E 8th ST PO Box 128 410 N Pomeroy 108 S Glenn PO Box 487 Dodge City, KS 67801 Ottawa, KS 66067 Junction City, KS 66441 Gove, KS 67736 Hill City, KS 67642 Ulysses, KS 67880 Cimarron, KS 67835-0487 Phone: (620) 227-4553 Phone: (785) 229-3410 Phone: (785) 238-3912 Phone: (785) 938-2300 Phone: (785) 421-3453 Phone: (620) 356-1335 Phone: (620) 855-3618 Fax: (620) 227-4699 Fax: (785) 229-3419 Fax: (785) 238-5419 Fax: (785) 938-2305 Fax: (785) 421-6374 Fax: (620) 356-3081 Fax: (620) 855-3107

Greeley County Greenwood County Hamilton County Harper County Harvey County Haskell County Hodgeman County P.O. Box 277 311 N Main PO Box 1167, 219 N Main 201 N Jennings PO Box 687, 8th & Main PO Box 518, 300 Inman St 500 Main Tribune, KS 67879 Eureka, KS 67045 Syracuse, KS 67878 Anthony, KS 67003 Newton, KS 67114 Sublette, KS 67877 Jetmore, KS 67854 Phone: (620) 376-4256 Phone: (620) 583-8121 Phone: (620) 384-5629 Phone: (620) 842-5555 Phone: (316) 284-6842 Phone: (620) 675-2263 Phone: (620) 357-6421 Fax: (620) 376-4255 Fax: (620) 583-8124 Fax: (620) 384-5853 Fax: (620) 842-3455 Fax: (316) 284-6856 Fax: (620) 675-2681 Fax: (620) 357-6313

Jackson County Jefferson County Jewell County Johnson County Kearny County Kingman County Kiowa County 400 New York PO Box 321 307 N Commercial 2101 E Kansas City Rd PO Box 86, 304 N Main 130 N Spruce 211 East Florida Avenue Holton, KS 66436 Oskaloosa, KS 66066 Mankato, KS 66956 Olathe, KS 66061 Lakin, KS 67860 Kingman, KS 67068 Greensburg, KS 67054 Phone: (785) 364-2891 Phone: (785) 863-2272 Phone: (785) 378-4020 Phone: (913) 782-3441 Phone: (620) 355-6422 Phone: (620) 532-2521 Phone: (620) 723-3366 Fax: (785) 364-4204 Fax: (785) 863-3135 Fax: (785) 378-3037 Fax: (913) 791-1753 Fax: (620) 355-7382 Fax: (620) 532-5082 Fax: (620) 723-3234

Labette County Lane County Leavenworth County Lincoln County Linn County Logan County Lyon County PO Box 387, 501 Merchant PO Box 788, 144 S Lane 300 Walnut 216 E Lincoln Ave P.O. Box 350 710 W 2nd 430 Commercial Oswego, KS 67356 Dighton, KS 67839 Leavenworth, KS 66048 Lincoln, KS 67455 Mound City, KS 66056 Oakley, KS 67748 Emporia, KS 66801 Phone: (620) 795-2138 Phone: (620) 397-5356 Phone: (913) 684-0422 Phone: (785) 524-4757 Phone: (913) 795-2668 Phone: (785) 671-4244 Phone: (620) 341-3245 Fax: (620) 795-2928 Fax: (620) 397-5419 Fax: (913) 680-1489 Fax: (785) 524-5008 Fax: (913) 795-2889 Fax: (785) 671-3341 Fax: (620) 341-3415

McPherson County Marion County Marshall County Meade County Miami County Mitchell County Montgomery County 117 N. Maple 200 S. Third St. Suite 104 1201 Broadway PO Box 278 201 S. Pearl Suite 102 PO Box 190, 111 S Hersey PO Box 446, 217 E Myrtle McPherson, KS 67460 Marion, KS 66861 Marysville, KS 66508 Meade, KS 67864 Paola, KS 66071 Beloit, KS 67420 Independence, KS 67301 Phone: (620) 241-3656 Phone: (620) 382-2185 Phone: (785) 562-5361 Phone: (620) 873-8700 Phone: (913) 294-3976 Phone: (785) 738-3652 Phone: (620) 330-1200 Fax: (620) 241-1168 Fax: (620) 382-8815 Fax: (785) 562-5262 Fax: (620) 873-8713 Fax: (913) 294-9544 Fax: (785) 738-5524 Fax: (620) 330-1202

Morris County Morton County Nemaha County Neosho County Ness County Norton County Osage County 501 West Main PO Box 1116, 1025 Morton St. PO Box 186, 607 Nemaha PO Box 138, 100 S Main 202 W Sycamore PO Box 70, 105 S Kansas PO Box 226, 717 Topeka Ave Council Grove, KS 66846 Elkhart, KS 67950 Seneca, KS 66538 Erie, KS 66733 Ness City, KS 67560 Norton, KS 67654 Lyndon, KS 66451-0226 Phone: (620) 767-5518 Phone: (620) 697-2157 Phone: (785) 336-2170 Phone: (620) 244-3811 Phone: (785) 798-2401 Phone: (785) 877-5710 Phone: (785) 828-4812 Fax: (620) 767-6789 Fax: (620) 697-2159 Fax: (785) 336-3373 Fax: (620) 244-3810 Fax: (785) 798-3180 Fax: (785) 877-5794 Fax: (785) 828-4749

Osborne County Ottawa County Pawnee County Phillips County Pottawatomie County Pratt County Rawlins County PO Box 160, 423 W Main 307 N Concord Suite 130 715 Broadway 301 State St. PO Box 187, 207 N 1st PO Box 885, 300 S 607 Main Osborne, KS 67473 Minneapolis, KS 67467 Larned, KS 67550 Phillipsburg, KS 67661 Westmoreland, KS 66549 Ninnescah Atwood, KS 67730 Phone: (785) 346-2431 Phone: (785) 392-2279 Phone: (620) 285-3721 Phone: (785) 543-6825 Phone: (785) 457-3314 Pratt, KS 67124 Phone: (785) 626-3351 Fax: (785) 346-5252 Fax: (785) 392-2011 Fax: (620) 285-2559 Fax: (785) 543-6827 Fax: (785) 457-3507 Phone: (620) 672-4110 Fax: (785) 626-9019 Fax: (620) 672-9541

Reno County Republic County Rice County Riley County Rooks County Rush County Russell County 125 W 1st Ave 1815 M. St. 101 W Commercial 110 Courthouse Plaza 115 N Walnut PO Box 220, 715 Elm PO Box 113, 4th & Main Hutchinson, KS 67501 Belleville, KS 66935-0429 Lyons, KS 67554 Manhattan, KS 66502 Stockton, KS 67669 LaCrosse, KS 67548 Russell, KS 67665 Phone: (620) 694-2732 Phone: (785) 527-7231 Phone: (620) 257-2232 Phone: (785) 537-6300 Phone: (785) 425-6391 Phone: (785) 222-2731 Phone: (785) 483-4641 Fax: (620) 694-2534 Fax: (785) 527-2668 Fax: (620) 257-3039 Fax: (785) 537-6394 Fax: (785) 425-6015 Fax: (785) 222-3559 Fax: (785) 483-5725

Saline County Scott County Sedgwick County Seward County Shawnee County Sheridan County Sherman County 300 W Ash, Ste. #215 303 Court 510 N Main Ste 100, 515 N Washington 3420 SW Van Buren P.O. Box 899, 925 9th St. 813 Broadway, Rm 102 Salina, KS 67401 Scott City, KS 67871 Wichita, KS 67203-3798 Liberal, KS 67901 Topeka, KS 66611 Hoxie, KS 67740 Goodland, KS 67735 Phone: (785) 309-5820 Phone: (620) 872-2420 Phone: (316) 660-7100 Phone: (620) 626-3355 Phone: (785) 251-5900 Phone: (785) 675-3361 Phone: (785) 890-4802 Fax: (785) 309-5826 Fax: (620) 872-7145 Fax: (316) 660-7125 Fax: (620) 626-3211 Fax: (785) 251-5999 Fax: (785) 675-3487 Fax: (785) 890-4809

Smith County Stafford County Stanton County Stevens County Sumner County Thomas County Trego County 218 S Grant 209 N B’way, Courthouse PO Box 190, 201 N Main 200 E 6th 501 N Washington 300 N Court 216 Main Smith Center, KS 66967 St. John, KS 67576 Johnson, KS 67855 Hugoton, KS 67951 Wellington, KS 67152 Colby, KS 67701 WaKeeney, KS 67672 Phone: (785) 282-5110 Phone: (620) 549-3509 Phone: (620) 492-2140 Phone: (620) 544-2541 Phone: (620) 326-3395 Phone: (785) 460-4500 Phone: (785) 743-5773 Fax: (785) 282-5114 Fax: (620) 549-3481 Fax: (620) 492-1745 Fax: (620) 544-4094 Fax: (620) 326-2116 Fax: (785) 460-4503 Fax: (785) 743-5594

Wabaunsee County Wallace County Washington County Wichita County Wilson County Woodson County Wyandotte County PO Box 278, 215 Kansas PO Box 70 214 C St PO Drawer 968, 206 S 4th St 615 Madison Room 103, 105 W Rutledge 850 State Avenue Alma, KS 66401 Sharon Springs, KS 67758 Washington, KS 66968 Leoti, KS 67861 Fredonia, KS 66736 Yates Center, KS 66783 Kansas City, KS 66101 Phone: (785) 765-2421 Phone: (785) 852-4282 Phone: (785) 325-2974 Phone: (620) 375-2731 Phone: (620) 378-2186 Phone: (620) 625-8605 Phone: (913) 573-8500 Fax: (785) 765-3704 Fax: (785) 852-5283 Fax: (785) 325-2303 Fax: (620) 375-4350 Fax: (620) 378-3841 Fax: (620) 625-8670 Fax: (913) 573-8580