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Request for Agent Delivery Office of the Minnesota of Absentee Ballot Secretary of State In accordance with Minnesota Statute 203B.11, subdivision 4, I, certify that I: (Name of Voter) am a patient in Health care facility (M.S. 144.50 and M.S. 144A.02) am a resident in Residential facility, shelter for battered women, or assisted living facility (M.S. 245A.02 Subd. 14) (M.S. 611A.37 Subd. 4) (M.S. 144G) would have difficulty getting to the polls because of incapacitating health reasons or have a disability. and request that the auditor or clerk provide the absentee ballot in a sealed transmittal envelope to, for delivery to me during the (Name of agent) seven days before the election or before 2:00 p.m. on election day. I certify that I have a pre-existing relationship with this person. (Date) (Signature of Voter) NOTE: This form must be accompanied by an absentee ballot application in order for the ballot to be released to the agent.