Printable Request Form [PDF]

ANN McFALL, SUPERVISOR OF ELECTIONS
ABSENTEE BALLOT REQUEST FORM

Date:

Voter Registration Number
(if known)

Last Name:

 First Name

Middle Name

Date of Birth

 Phone Number

E-mail Address:

VOTER'S PERMANENT VOLUSIA COUNTY RESIDENCE ADDRESS (REQUIRED)

Street Address

Apt./Unit/Lot

City

 State Zip Code

VOTER'S PERMANENT MAILING ADDRESS (IF DIFFERENT THAN RESIDENCE ADDRESS)

Street Address

Apt./Unit/Lot

City

 State Zip Code

ALTERNATIVE MAILING ADDRESS

Street Address

 Apt./Unit/Lot

City

 State Zip Code

ALTERNATIVE MAILING INSTRUCTIONS

Absentee ballots will be mailed to the mailing address on file unless specified otherwise (select any items that may apply to you below):

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.

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.
    OR

Specific Election (please list):    

Absentee Status:
(Select one)
Civilian Military- Overseas Military Dependent- Overseas
Civilian Overseas Military- Stateside Military Dependent- Stateside

REQUEST BY IMMEDIATE FAMILY OR LEGAL GUARDIAN FOR VOTER

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

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)

Ann McFall, Supervisor of Elections
125 West New York Avenue, DeLand, FL 32720-5415
Area Code for all numbers is (386)
W. Volusia 736-5930 N.E. Volusia 254-4690 S.E. Volusia 423-3311 Osteen Area 574-0598, ext. 5930