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) Individual with a Disability Application for Electronic Absentee Ballot Including Absentee List Request, Election Specific Absentee Ballot Request and Request for Absentee Ballot Due to Illness or Health Emergency 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 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 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 emailed to me for ALL elections in which I am eligible to vote as long as I remain qualified to receive an electronic ballot as an individual with a disability. 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 am eligible to receive and vote an electronic ballot because I am an individual with a temporary or permanent physical impairment such as impaired vision, impaired hearing or impaired mobility in accordance with 13-3-202, Montana Code Annotated, and 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 – If elector is unable to sign, may use fingerprint, mark or Agent *Date Signed Optional - Voter Information Pamphlet Request (an electronic version of this pamphlet can be found at sosmt.gov) Please send current Voter Information Pamphlet, if applicable to this election. Audio and large-print versions of the Voter Information Pamphlet are available online at: http://www.sosmt.gov/elections/Disabilities, and a Braille version is available upon request. Application for Electronic Absentee Ballot may be mailed to or dropped off at the county election office; see http://sos.mt.gov/portals/142/Elections/forms/electionadministrators.pdf for contact information. Updated August 11, 2020 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 8:00 p.m. on election day. Signature of Elector Date Signed