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*Indicatesrequiredinformation

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

Email

Primary

SchoolCitySpecial:

ElectionDate:
//

PrimaryElectionsOnly:checkonepoliticalparty

Democratic

Republican

REQUESTERAFFIDAVIT*
(Powersofattorneydonothavelegal
authoritytorequestanabsentee
ballotonbehalfofanother.)

IswearoraffirmthatIamthepersonnamedaboveandIamaregisteredvoterorIamentitledtoregisterattheaddresslistedonthisform.
Iameligibletoreceiveandvoteanabsenteeballotfortheelectionindicatedabove.

Signature

Date

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