|
ATTENTION
HENRY COUNTY
ELECTION COMMISSION
I formally
“Request an Absentee Ballot” based upon the
following information.
1)
PRINT NAME
______________________________________________________________
2)
ADDRESS ON VOTER REGISTRATION
___________________________________________________
3)
MAIL MY ABSENTEE
BALLOT TO THIS ADDRESS
________________________________________
4)
MY SOCIAL SECURITY # IS
_________________________________________________
5)
MY DATE OF BIRTH IS
_____________________________________________________
6)
I wish to vote in the:
Election
(please
indicate ___ Republican or ___ Democratic)
Other
7) MY LEGAL REASON
FOR VOTING ABSENTEE
(Check One)
____ I am over 60
years of age.
____ I will be
outside of this county during all hours of
early voting and Election
Day (must include mailing
address outside county to mail absentee
ballot)
____
I am enrolled as a full-time student
(or I am the spouse of a student) at an
institution inside Tennessee and outside the county where I am
registered.
____
I am a voter with a disability and my
polling place is inaccessible.
____ I am a member of the military, or I am a family
member to the member of the military or I am
an overseas citizen and otherwise qualified
to vote in
Tennessee.
Ballot to be sent:
0
By Mail
0
Electronically, e-mail address:
_____________________
____ I reside in a licensed facility, outside the
county, providing relatively permanent
domiciliary care (Nursing Home).
____ I am hospitalized, ill or physically disabled and
because of such condition, I am unable to
appear at my polling place for this
election.
____ I am a
caretaker of a person who is hospitalized,
ill or physically disabled.
____ I am a
candidate.
____ I am on jury duty in a state or
federal court.
____Other
____ I am serving
as an election official or a member or
employee of the election commission on
Election Day.
____ I am
observing a religious holiday that prevents
me from voting early or on Election Day.
____ I have a Commercial Drivers License, will be out of
county during the open hours of early voting
& Election Day, & have no specific
out-of-county or out-of-state address to
receive mail during this time.
***My CDL # is ______________________
8) SIGNATURE OF
VOTER
__________________________________________________
If voter is unable to sign their name, or receives assistance with this
form, the person assisting and one witness
must also sign their name and address.
1.____________________________________________________________________________
Name and address of person assisting
2.____________________________________________________________________________
Name and address of person witnessing
============================================================================
FOR
_____________ COUNTY ELECTION OFFICE USE:
(Circle One)
This Request has been:
Approved -
Rejected
on ___________ by _______________
Voting Precinct/District
_____________ Application Signature verified
on ________by____________
Ballot Sent _______ Ballot
Rcvd ________
Ballot Affidavit Signature verified
on_______by________
BALLOT INFORMATION
Mail to: Henry County Election Commission
▪
PO Box 967
▪
Paris TN 38242
Or Fax the Completed Form to: (731) 644-7302 |
