STATEOFIOWAOFFICIALABSENTEEBALLOTREQUESTFORM
FOROFFICEUSEONLY
Last
YOURNAME*AND
DATEOFBIRTH*
First
Middle
Suffix
DateofBirth(month,day,year)//
IDNUMBER
(Checkandcompleteone)
IowaDriversLicenseorNonOperatorIDNumber:
LastFourDigitsofSocialSecurityNumber: XXXXX
HomeStreetAddress(includeapt,lot,etc.ifapplicable)
City
WHEREYOUR
ABSENTEEBALLOT
SHOULDBEMAILED
(Ifdifferentthanabove)
CONTACTINFO
ELECTIONTYPEORDATE*
Revised 7/1/2014
Youmustberegisteredtovoteinthecountytoreceiveanabsenteeballot.Ifyouareregisteredtovoteinthecounty,thisformwillbeusedto
updateyourvoterregistrationiftheinformationprovidedonthisformisdifferentthantheinformationonyourregistrationrecord.
YOURIOWA
RESIDENTIALADDRESS*
(Provideelectiontypeordate.Choose
onlyoneelection.)
PARTYAFFILIATION
Zip
County
State
Zip
Address/P.O.Box
City
Country(otherthanUSA)
Phone
General
OR
Primary
SchoolCitySpecial:
ElectionDate:
//
PrimaryElectionsOnly:checkonepoliticalparty
Democratic
Republican
REQUESTERAFFIDAVIT*
(Powersofattorneydonothavelegal
authoritytorequestanabsentee
ballotonbehalfofanother.)
IswearoraffirmthatIamthepersonnamedaboveandIamaregisteredvoterorIamentitledtoregisterattheaddresslistedonthisform.
Iameligibletoreceiveandvoteanabsenteeballotfortheelectionindicatedabove.
Signature
Date