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Application for Absentee Ballot Including Absentee List Request, Election Specific Absentee Ballot Request, Request for Absentee Ballot Due to Illness or Health Emergency or to be removed from receiving an Absentee Ballot. Fields marked with an asterisk are required fields. Please type or use black or blue pen only and print clearly. COMPLETE FORM AND SUBMIT TO COUNTY ELECTION OFFICE BY NOON THE DAY BEFORE ELECTION DAY APPLICANT IDENTIFYING AND CONTACT INFORMATION Last Name* First Name* Middle Name (Optional) Birthdate* (MM/DD/YYYY) Phone Number (Optional) Email Address (Optional) County where you reside and are registered to vote* Montana Residence Address* City* Zip Code* Mailing Address (required if differs from residence address*) City and State Zip Code Check if the mailing address listed above is for part of the year only and if so, complete the information below (for absentee ballot list only). Clearly print the complete mailing address(es) and specify the applicable time periods for address (add more addresses as necessary). Seasonal Mailing Address (Optional) City and State Zip Code Period (mm/dd/yyyy-mm/dd/yyyy) BALLOT REQUEST OPTIONS AND VOTER AFFIRMATION Yes, I request an absentee ballot to be mailed to me for ALL elections in which I am eligible to vote as long as I reside at the address listed on this application. I understand that if I file a change of address with the U.S. postal service, I must complete, sign, and return a confirmation notice mailed to me by the county election office; OR I hereby request an absentee ballot for the upcoming election (check only one): Primary General Municipal Other election to be held on By signing below, I understand that I am officially requesting an absentee ballot and affirm that I will have met the 30-day Montana residency requirement before voting my absentee ballot. (Also sign affidavit at bottom of page if requesting due to illness or health emergency.) *Signature of Elector *Date Signed Optional – Voter Information Pamphlet Request (An electronic version of this pamphlet can be found at sosmt.gov/elections.) Please send current Voter Information Pamphlet, if applicable to this election Optional – Designate another person to pick up your absentee ballot I, the elector who signed below, hereby designate to pick up my absentee ballot. Receipt of absentee ballot by designee: I received the absentee ballot for the applicant on . Date ballot received Signature of Designee Signature of Elector Date Signed Optional – Revert to Non-Absentee Voter (This would revert you to only voting at your local polling place.) Please check this box to affirm that you do NOT want to receive an absentee ballot and instead want to vote at your local polling place on election day. Optional – Affidavit of elector (due to illness or health emergency) Optional: I hereby declare that I am prevented from voting at the polls due to illness or health emergency occurring between 5:00 p.m. on the Friday preceding the election and 8 p.m. on election day. Signature of Elector Date Signed Updated September 10, 2019 ---PAGE BREAK--- Montana Secretary of State - County Election Administrator Contact List COUNTY NAME ADDRESS CITY/STATE/ZIP PHONE FAX E-MAIL Beaverhead Stacey Reynolds 2 S Pacific St No 3 Dillon MT 59725 (406) 683-3720 (406) 683-3781 [EMAIL REDACTED] Big Horn Dulcie Bear Don't Walk PO Box 908 Hardin MT 59034 (406) 665-9796 (406) 665-9824 Blaine Tammy Williams PO Box 278 Chinook MT 59523 (406) 357-3240 (406) 357-2199 [EMAIL REDACTED] Broadwater Doug Ellis 515 Broadway St Townsend MT 59644 (406) 266-3443 (406) 266-3674 [EMAIL REDACTED] Carbon Macque Bohleen PO Box 887 Red Lodge MT 59068 (406) 446-1220 (406) 446-2640 [EMAIL REDACTED] Carter Pamela Castleberry Box 315 Ekalaka MT 59324 (406) 775-8749 (406) 775-8750 Cascade Rina Moore Box 2305 Great Falls MT 59403 (406) 454-6803 (406) 454-6725 Chouteau Lana Claassen Box 459 Fort Benton MT 59442 (406) 622-5151 (406) 622-3012 [EMAIL REDACTED] Custer Linda Corbett 1010 Main Miles City MT 59301 (406) 874-3343 (406) 874-3452 [EMAIL REDACTED] Daniels Kristy Jones Box 247 Scobey MT 59263 (406) 487-5561 (406) 487-5583 [EMAIL REDACTED] Dawson Shirley Kreiman 207 West Bell Glendive MT 59330 (406) 377-3058 (406) 377-1717 [EMAIL REDACTED] Deer Lodge Amanda Wilson 800 Main Anaconda MT 59711 (406) 563-4046 (406) 563-4078 [EMAIL REDACTED] Fallon Brenda Wood Box 846 Baker MT 59313 (406) 778-7106 (406) 778-2048 [EMAIL REDACTED] Fallon Kathy Newell Box 846 Baker MT 59313 (406) 778-7106 (406) 778-2048 [EMAIL REDACTED] Fergus Rana Wichman 712 W Main Lewistown MT 59457 (406) 535-5242 (406) 535-9023 [EMAIL REDACTED] Flathead Debbie Pierson 40 11th St W Ste 230 Kalispell MT 59901 (406) 758-5535 (406) 758-5877 [EMAIL REDACTED] Gallatin Eric Semerad 311 W Main Rm 210 Bozeman MT 59715 (406) 582-3060 (406) 582-3068 [EMAIL REDACTED] Gallatin Casey Hayes 311 W Main Rm 210 Bozeman MT 59715 (406) 582-3060 (406) 582-3068 [EMAIL REDACTED] Garfield Patty Sewell PO Box 7 Jordan MT 59337 (406) 557-2760 (406) 557-2765 [EMAIL REDACTED] Glacier Mandi Bird Kennerly 512 E Main Cut Bank MT 59427 (406) 873-3609 (406) 873-3613 Golden Valley Brent Nice PO Box 10 Ryegate MT 59074 (406) 568-2231 (406) 568-2428 [EMAIL REDACTED] Granite Sarah Graham Box 925 Philipsburg MT 59858 (406) 859-3771 (406) 859-3817 [EMAIL REDACTED] Hill Susan 315 4th St Havre MT 59501 (406) 265-5481 x221 (406) 265-2445 Jefferson Bonnie Ramey Box H Boulder MT 59632 (406) 225-4020 (406) 225-4149 [EMAIL REDACTED] Judith Basin Amanda Kelly Box 427 Stanford MT 59479 (406) 566-2277 x109 (406) 566-2211 [EMAIL REDACTED] Lake Katie Harding 106 4th Ave E Polson MT 59860 (406) 883-7268 (406) 883-7230 [EMAIL REDACTED] Lewis & Clark Paulette DeHart 316 N Park Ave Rm 168 Helena MT 59623 (406) 447-8339 (406) 457-8598 Lewis & Clark Audrey McCue 316 N Park Ave Rm 168 Helena MT 59623 (406) 447-8339 (406) 457-8598 Liberty Davin Buffington Box 459 Chester MT 59522 (406) 759-5365 (406) 759-5395 Lincoln Leigh Riggleman 512 California Libby MT 59923 (406) 283-2302 (406) 293-8577 [EMAIL REDACTED] Madison Kathleen Mumme Box 366 Virginia City MT 59755 (406) 843-4270 (406) 843-5264 McCone Maridel Kassner Box 199 Circle MT 59215 (406) 485-3505 (406) 485-2689 [EMAIL REDACTED] Meagher Dayna Ogle Box 309 White Sulphur Springs MT 59645 (406) 547-3612 x2 (406) 547-3388 [EMAIL REDACTED] Mineral Kelann McLees Box 550 Superior MT 59872 (406) 822-3520 (406) 822-3579 [EMAIL REDACTED] Missoula Bradley Seaman 140 N Russell St Missoula MT 59801 (406) 258-4751 (406) 258-3913 [EMAIL REDACTED] Musselshell Cheryl Tomassi 506 Main Roundup MT 59072 (406) 323-1104 (406) 323-3303 [EMAIL REDACTED] Park Maritza Reddington 414 E Callender St Livingston MT 59047 (406) 222-4110 (406) 222-4193 [EMAIL REDACTED] Petroleum Janel Tucek Box 226 Winnett MT 59087 (406) 429-5311 (406) 429-6328 Phillips Lynnel LaBrie Box 360 Malta MT 59538 (406) 654-2423 (406) 654-2429 [EMAIL REDACTED] Pondera Kody Farkell 20 4th Ave SW Conrad MT 59425 (406) 271-4000 (406) 271-4070 [EMAIL REDACTED] Powder River Cynde Jo Gatlin Box 200 Broadus MT 59317 (406) 436-2361 (406) 436-2151 [EMAIL REDACTED] Powell Jody Walker 409 Missouri Deer Lodge MT 59722 (406) 846-9786 (406) 846-3891 Prairie Shari L Robertson Box 125 Terry MT 59349 (406) 635-5575 (406) 635-5576 [EMAIL REDACTED] Ravalli Regina Plettenberg 215 S 4th St Ste C Hamilton MT 59840 (406) 375-6550 (406) 375-6554 [EMAIL REDACTED] Richland Stephanie Verhasselt 201 W Main Sidney MT 59270 (406) 433-1708 (406) 433-3731 [EMAIL REDACTED] Roosevelt Cheryl Hansen 400 2nd Ave S Wolf Point MT 59201 (406) 653-6250 (406) 653-6289 [EMAIL REDACTED] Rosebud Joan Duffield Box 47 MT 59327 (406) 346-7318 (406) 346-7551 Sanders Nichol Scribner Box 519 Thompson Falls MT 59873 (406) 827-6922 (406) 827-6970 [EMAIL REDACTED] Sheridan Lindsey Brensdal 100 W Laurel Ave Plentywood MT 59254 (406) 765-3403 (406) 765-2609 [EMAIL REDACTED] Silver Bow Sally Hollis 155 W Granite Rm 208 Butte MT 59701 (406) 497-6342 (406) 497-6328 [EMAIL REDACTED] Stillwater Heidi Stadel Box 149 Columbus MT 59019 (406) 322-8000 (406) 322-8069 Sweet Grass Vera Pederson Box 888 Big Timber MT 59011 (406) 932-5152 (406) 932-3026 [EMAIL REDACTED] Teton Paula Jaconetty Box 610 Choteau MT 59422 (406) 466-2693 (406) 466-3244 Toole Treva Nelson 226 1st St S Shelby MT 59474 (406) 424-8300 (406) 424-8301 Treasure Marlee Sears Box 392 Hysham MT 59038 (406) 342-5547 (406) 342-5547 [EMAIL REDACTED] Valley Taryn Aberg 501 Court Sq Box 2 Glasgow MT 59230 (406) 228-6226 (406) 228-9027 Wheatland Mary Miller Box 1903 Harlowton MT 59036 (406) 632-4891 (406) 632-4880 [EMAIL REDACTED] Wibaux Jodee Chaffee PO Box 199 Wibaux MT 59353 (406) 796-2481 (406) 796-2625 [EMAIL REDACTED] Yellowstone Bret Rutherford Box 35002 Billings MT 59107 (406) 256-2740 (406) 254-7940 [EMAIL REDACTED] 5/21/2020