Brad Raffensperger Application for Georgia Official Absentee Ballot

Secretary of State The information provided in this document is made under oath and penalty of law and will be used for official
government purposes. When you sign this application, you affirm that you are a citizen of the U.S.,
currently reside in Georgia and are eligible to vote in Georgia. Giving false information on this application
violates Georgia law and is punishable by a fine up to $100,000, imprisonment for up to 10 years, or both.
Please print clearly. Be sure to complete all required sections.

Date of Election Date of Primary, Election, or Runoff (mm/dd/yyyy)

1
Required The application must be received by your election office* 11 days before the election.

Print voter name Your name as it appears on your voter registration.

Required 2
First Middle Last Suffix

Type of ballot
Required in primary
3 Democratic Republican Non Partisan (will not have ANY party candidates listed)

Residential address The residential or mailing address on your voter registration. If you no longer reside at the address where you
Required Your ballot will be are registered to vote, contact your county election office prior to submitting this application.
sent here unless you provide
4 Address
a temporary mailing address. City County GA Zip

Temporary ballot
This address must be in a different county** than the one where you are registered unless you are physically
mailing address disabled or detained in jail or other detention facility.
Only if you are temporarily 5
living outside the county** Address
and want your ballot
sent to this address. City State Zip

Contact information 6
Recommended Phone number Email address

Georgia Driver’s License Number or State Identification Card Number

Voter identification Date of birth (mm/dd/yyyy)
Required AND

Print carefully. This OR

information will be used I do not have a Georgia Driver’s License or Identification Card
to verify your identity. and I am providing a copy of acceptable identification below.

Failure to provide Instructions:

accurate information
may delay processing • Make sure your identification on your
your application. ID card or document is visible.

• Take a photo of your full completed

You must provide your 7 application and submit it
date of birth AND
electronically to your elections office* Place identification here
• a Georgia (addresses are online: elections.sos.
Driver’s License if you did not provide a Georgia
ga.gov/Elections/countyregistrars.
or Identification
do). You may also submit a hard copy
driver’s license or ID number
Card number
of your application via U.S. mail or in
OR
person to your elections office*.
• a copy of an
acceptable • If your acceptable form of
identification identification does not fit in this box,
from the list in please attach a copy and submit it
the instructions. with your application.

I, the undersigned, do swear and affirm that I am eligible to vote in Georgia, am a citizen of the U.S. and the facts
Voter oath and presented in this application are true. By signing this oath, you are swearing that you are the voter requesting an
signature absentee ballot.
Required Signing this oath on behalf of another voter violates Georgia law and is punishable by a fine up to
$100,000, imprisonment for up to 10 years, or both.
Use a pen. No electronic 8
signatures allowed. Voter, sign and date here (Required)
Date (mm/dd/yyyy)
X

If you received this application with your information pre-filled, received multiple or duplicate copies in the mail, or if an unauthorized person
offers to return your absentee ballot application, please report this to reportfraud@sos.ga.gov. Form continues ►
APP-21
 Brad Raffensperger
Secretary of State Application for Georgia Official Absentee Ballot
Your name as it appears on your voter registration.
Print voter name 9
Required First Middle Last Suffix

By signing as assisting the voter, you are swearing under oath that the voter is entitled to assistance. Assisting
Assisting a voter?
a voter who is not eligible for assistance in completing this application violates Georgia law and is punishable by
If yes, the assistant must a fine up to $100,000 or imprisonment for up to 10 years, or both.
complete this section. Voter
assistance is only allowed
10 Assistant’s name
if the voter is illiterate Date (mm/dd/yyyy)
Assistant’s
or physically disabled.
signature
X

Requesting a ballot I swear that the facts contained in this application I swear (or affirm) that the above-named voter is:
on behalf of a voter? are true and that I am either the mother, father, (check one)
If yes, complete this section. grandparent, brother, sister, aunt, uncle, spouse,
physically disabled
The voter must be physically son, daughter, niece, nephew, grandchild,
temporarily residing out of the county**
disabled or temporarily son-in-law, daughter-in-law, mother-in-law,
residing out of the county** 11 father-in-law, brother-in-law or sister-in-law of Signature of authorized and eligible requestor
and must still be eligible to the age of 18 and acknowledge that making a
false statement on this application regarding
vote in the county** where X
he or she is registered. my relationship to the voter violates Georgia
law and is punishable by a fine up to $1,000,
12 months in jail, or both. Relationship to voter

Ballot request I opt-in to receive an absentee ballot for UOCAVA Voters only
opt-in the rest of the election cycle.
My current status is (check one)
Optional I am eligible for the reason selected below:
If you meet the eligibility MOS - Military Overseas
D- Disabled. I am physically disabled MST - Military Stateside
criteria, you may opt-in to
receive an absentee ballot E- Elderly. I am 65 years of age or older OST - Overseas Temporary Resident
12 U- UOCAVA. I am a uniformed service
for the rest of the elections OSP - Overseas Permanent Resident
cycle without making member, spouse or dependent of a (may vote for federal offices only)
another application. uniformed service member, or other US
citizen residing overseas. (Complete the (Optional) By entering my email, I request that my absentee
information to the right) ballot be transmitted to me electronically.

Email

Acceptable forms of identification if you How to return your absentee ballot application
do not have a Georgia Driver’s License or Absentee ballot applications must be received 11 days before the date of the election.
State Identification Card Number You can return the form by:
Identification with your photograph: • mail • email (as an attachment)
• United States Passport • fax • in-person at your elections or registrar’s office
• Georgia voter identification card Your County Board of Registrar’s Office information can be found online:
• Other valid identification card issued by a branch, department, https://elections.sos.ga.gov/Elections/countyregistrars.do
agency, or entity of the State of Georgia, any other state, or the
United States authorized by law to issue personal identification *In state, county, and federal elections, your elections office is your county elections
• United States military identification card office. In municipal elections, your elections office is your municipal elections office.
• Employee identification card issued by any branch, department, **Or, in municipal elections, municipality.
agency, or entity of the United States government, Georgia state
No person or entity other than the elector, a relative authorized to request an absentee
government, or Georgia county, municipality, board, authority, or
ballot for such elector, a person signing as assisting an illiterate or physically disabled
any other entity of the state of Georgia
elector with his or her application, a common carrier charged with returning the ballot
• Tribal identification card application, an absentee ballot clerk, a registrar, or a law enforcement officer in the
Documents that show your name and address: course of an investigation shall handle or return an elector’s completed absentee ballot
• Current utility bill • Bank statement • Paycheck application. Handling a completed absentee ballot application by any person or
• Government check • Other government document entity other than as allowed in this paragraph is a misdemeanor.

Ballot Dates ID Shown For office use only

Dist. Combo Received GA DL I certify that the above named voter
Precinct ISS Other is eligible
Ballot # Certified Voter Reg # is not eligible

Rejected Registrar signature

Mailed Delivered to voter in hospital Voted in office

Ballot to be:
electronically by Registrars or Deputy (municipal only)