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ANN McFALL, SUPERVISOR OF ELECTIONS
ABSENTEE BALLOT REQUEST FORM
   

Date:  

Voter Registration Number (if known)  

Phone Number  

First Name  

Middle Name  
 
Last Name  

Date-of-Birth  
(required)  

E-Mail Address  

Fax Number
VOLUSIA COUNTY RESIDENCE ADDRESS (REQUIRED) Address listed below is a new address, please update.
                  (Only the voter may make this change)

Street Address  

Apt/Unit/Lot  

City  

    State

Zip Code  

PERMANENT MAILING ADDRESS  (IF DIFFERENT THAN RESIDENCE ADDRESS)

Street Address  

Apt/Unit/Lot  

City  

    State

Zip Code  

ALTERNATIVE MAILING ADDRESS INSTRUCTIONS

Absentee ballots must be mailed to the mailing address on file, unless the voter is (select one):

Absent from the county, and will not return before the day of the election.

Temporarily unable to occupy the Volusia County residence because of a natural disaster.

In a hospital, assisted living facility, nursing home, short-term medical or rehabilitation facility, or correctional facility.

Alternate
Mailing Address

Apt/Unit/Lot  

City  

    State

Zip Code  

OVERSEAS AND MILITARY/MILITARY DEPENDENT VOTERS (ONLY)
Method in which to receive ballot:

Email, please provide email address above.

Fax, please provide fax number above.

Mail, please provide mailing address, if different from above.
BALLOT REQUEST IS FOR (SELECT CHOICE THAT APPLIES)

All elections for which I am eligible to vote through the next regularly scheduled general election (2012).

Specific Election (current year):
REQUEST BY IMMEDIATE FAMILY OR LEGAL GUARDIAN FOR VOTERS

If you are requesting an absentee ballot for an immediate family member or are a legal guardian, you must complete this section.

    I have been instructed by the voter to make this request.

Requestor's Name

 Relationship to the voter (Required)

Requestor's Complete Address 

Requestor's Driver's License Number (if available)