REQUEST FOR MISSOURI ABSENTEE BALLOT

I, , do hereby request an absentee ballot for the

Printed name

Election.

Election Date

For identification purposes, the last four digits of my social security number are: .

If this is a primary election, please print the name of the political party ballot you wish to receive: .

Reason for requesting an absentee ballot:

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 on election day, including caring for a person who is

incapacitated or confined due to illness or disability and resides at the same address;

Religious belief or practice

Employment as an election authority or by an election authority at a location other than my polling place, a first

responder, a health care worker, or a member of law enforcement;

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

because of safety concerns.

Address where I am registered to vote:

(Street Address)

(City, State, Zip Code)

Address where ballot is to be mailed:

(Street Address or PO Box)

(City, State, Zip Code)

Telephone number:

(Include Area Code)

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

Mail this completed form to your local election authority. Addresses can be found on the Missouri Secretary of State’s website. Missouri

law requires that requests for absentee ballots must be received by 5:00 p.m. on the second Wednesday prior to Election Day if the

ballot is mailed. The deadline for absentee voting in person in the office of the election authority is 5:00 p.m. on the day before the

election. If you registered by mail and this is your first time voting, you must provide a copy of either: (1) a nonexpired Missouri driver’s

or nondriver’s license; (2) a nonexpired military ID, including a veteran’s ID card; (3) a nonexpired United States passport; or (4) another

photo ID issued by the United States or the state of Missouri which is either not expired or expired after the date of the most recent

general (November) election.

§§ 115.279, 115.283, 115.284, 115.427 (8/2022)

PL 107-252