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Name: Date of Birth: I do hereby request a replacement ballot for the election held 20 in County, Montana. Reason for replacement ballot request (select one): □ I did not receive the ballot issued to me. □ I made a mistake on my ballot or it was lost, damaged, spoiled, or destroyed. □ My ballot contains a print error or print omission. □ Other (specify): Replacement Ballot Request Options (select one): □ I, the elector, request a replacement ballot in person. □ I, the elector, request a replacement ballot be provided to the person designated below. □ I, the elector, request a replacement ballot be mailed to me at the following address: STATEMENT OF ELECTOR I hereby affirm, under penalty of law, that the above information is true and correct, and that I understand attempting to vote more than once in any election is a violation of Montana election law. Signature of Elector Date Updated September 21, 2018 Replacement Ballot Request This form is used by an absentee, late registration, or mail ballot election voter to request a replacement ballot due to the first ballot being spoiled, damaged, destroyed, or not received. This request may only be used if the voter has not yet returned the voted ballot to the county election office. A request for a replacement ballot submitted to the election administrator must be made on this form and must be submitted in person, by regular or electronic mail, or by facsimile no later than 8 p.m. on election day. TO BE FILED WITH COUNTY ELECTION ADMINISTRATOR OPTIONAL - DESIGNATE ANOTHER PERSON TO PICK UP YOUR BALLOT I, the elector who signed below, hereby designate to pick up my replacement ballot. Receipt of replacement ballot by designee: I received the absentee ballot for the applicant on (Date ballot received) Signature of Elector (signed in advance) Signature of Designee (signed when ballot is received)