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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  

 

  
E-Mail Address  

Date-of-Birth  
(required)  

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  

BALLOT REQUEST IS FOR (SELECT CHOICE THAT APPLIES)
All elections for which I am eligible to vote through the next two regularly scheduled general elections (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)