REQUEST FOR ABSENTEE BALLOT

Name of Absentee Voter:___________________________________________________________

Current Mailing Address: __________________________________________________________

Town of Residence: ______________________________________________________________

                                                             (if different from current mailing address)

Address to which ballots are to be mailed:___________________________________________

_______________________________________________________________________________

Which election is the absentee ballot requested for?

_____  Annual Meeting

_____  Special Meeting

_____  Primary Election

_____  General Election

_____  Presidential Primary: (please circle desired ballot)          Democratic       Republican         

PLEASE NOTE:  A single request may be made for absentee ballots for the Primary and General Elections, as long as the "mail to" address is the same for both elections.  However, separate requests must be made for annual and special meetings and the Presidential Preference Primary.

If application is made by a family member or person authorized by the absentee voter:

Name of Applicant:  _______________________________________________

Address of Applicant: _____________________________________________

Relationship to Absentee Voter: ___________________________________

("Family member" includes the voters's spouse, children, brothers, sisters, parents, spouse's parents, grandparents, and spouse's grandparents.)

_______________________________________________  ________________

Signature of Authorized Applicant or Absentee Voter        Date

IMPORTANT:  If, after receiving your absentee ballot, you decide to vote in person you may do so, but only if you return the complete set of unmarked ballots, together with the envelope(s) intended for their return, to the presiding officer at the time you appear at the polls to vote in person.

You must send the completed request form to the town clerk of the town in which you are on the checklist.  For the mailing addresses of the town clerks, please look at our web site at www.sec.state.vt.us or call our office at 1-800-439-VOTE.