Absentee Ballot Application (COVID-19)

REQUEST FOR MISSOURI ABSENTEE OR MAIL-IN BALLOT
GENERAL ELECTION - NOVEMBER 3, 2020

Voter’s Name: __________________________________________________________________________________________

For identification purposes: Date of Birth (MM/DD/YY) ___________ or last four digits of Social Security number _________

Registered Voting Address: _____________________________________________________________________________

City: _________________________________________________________________ ZIP Code: _____________________

Telephone Number: ___________________________ Email Address: __________________________________________

Address to which ballot is to be mailed (if different than above):

Address: ____________________________________________________________________________________________

City: _________________________________________________________________ ZIP Code: _____________________

ABSENTEE BALLOT REQUEST (select ONE reason):
(NOTARY REQUIRED UNLESS SPECIFICALLY NOTED BELOW)

______ 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. (No Notary Required)
______ 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 have retained all the necessary qualifications for voting
______ Certified participation in the address confidentiality program established under sections 589.660 to 589.681, RSMo.,
. because of safety concerns
______ I have contracted or am in an at-risk category for contracting or transmitting severe acute respiratory syndrome . .
coronavirus 2 (COVID-19), pursuant to Section 115.277.6, RSMo. (No Notary Required)

At-risk voters are individuals who:
• Are 65 years of age or older • Live in a long-term care facility licensed under Chapter 198, RSMo.
• Have serious heart conditions • Have chronic lung disease or moderate to severe asthma
• Are immunocompromised • Have chronic kidney disease and are undergoing dialysis
• Have liver disease • Have diabetes
.
If you request an absentee ballot, this form may be returned to your local election authority in person, by mail, by fax, or by email.

MAIL-IN BALLOT REQUEST:
(NOTARY REQUIRED FOR ALL MAIL-IN BALLOTS)

_____ Any registered voter can request a mail-in ballot. If selecting this option, this form must be delivered to your
local election authority in person or by mail only.

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

Signature of Registered Voter Date

Return this completed form to Taney County Clerk PO BOX 156 Forsyth, Mo 65653. Missouri law requires that requests for ballots to be
mailed to you must be received by 5:00 p.m. on October 21, 2020.