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APPLICATION FOR ABSENTEE BALLOT BY MAIL ONLY IN 2022 FOR ELECTION ON / / 2022 State Form 47090 (R32 / 12-21) Indiana Election Division (IC 3-11-4-2; 3-11-4-5.1; 3-11-10-24) (ABS-MAIL) INSTRUCTIONS: Complete and return application so it is received by county election board at least twelve (12) days before election day. DEADLINE: For the May 3, 2022 Primary Election, deadline for county to RECEIVE is April 21, 2022 BY 11:59 p.m. (local prevailing time). For November 8, 2022 General Election, deadline for county to RECEIVE is OCTOBER 27, 2022 BY 11:59 p.m. (local prevailing time). THIS APPLICATION CAN BE MAILED, E-MAILED, FAXED, OR HAND-DELIVERED. If you receive this completed application from a voter, you must file the completed application with the county or Indiana Election Division by noon, ten (10) days after receiving it or by the absentee deadline, whichever comes first. You must provide the date you received the completed application in box 5. County of residence: 1. INFORMATION OF ABSENTEE BALLOT APPLICANT Name (Please print.) Date of birth (mm/dd/yy) / / Last Four Digits of Social Security Number (Completing this box is optional.) OR I do not have a Social Security Number. Change of Name (If you changed your name since you registered to vote, please print your FORMER NAME to authorize an update to your voter registration: Registration Address (number and street) City/Town, State, ZIP Code Telephone Number (Optional, if not filing online) ( ) E-mail Address (Optional) 2. ABSENTEE BALLOT MAILING ADDRESS (Please mail the absentee ballot for the election to me at this address if different from registration address.) Mailing Address (number and street) City/Town, State, ZIP Code 3. PRIMARY ELECTION ONLY Under state law, you must request a major political party ballot to vote in a primary election. You may vote on a public question without voting a political party ballot, if a referendum (public question) is held on the same day as the primary. I apply for the ballot of the political party, a majority of whose candidates I voted for at the last general election, or whom I intend to vote for in the next general election: DEMOCRATIC PARTY REPUBLICAN PARTY OR I do not wish to vote in either party’s primary but wish to vote on a PUBLIC QUESTION ONLY 4. REASON TO VOTE ABSENTEE BALLOT BY MAIL I have a specific, reasonable expectation of being absent from the county on election day during the entire twelve (12) hours that the polls are open. I will be confined to my residence, a health care facility, or a hospital due to illness or injury during the entire twelve (12) hours that the polls are open. I will be caring for an individual confined to a private residence due to illness or injury during the entire twelve (12) hours that the polls are open. I am a voter with disabilities. NOTE: If you are unable to mark the ballot or sign the ballot security envelope, you must contact the county election board to process your application. I am a voter at least sixty-five (65) years of age. I will have official election duties outside of my voting precinct. I am scheduled to work at my regular place of employment during the entire twelve (12) hours that the polls are open. I am unable to vote at the polls in person due to observance of a religious discipline or religious holiday during the entire twelve (12) hours the polls are open. I am a voter eligible to vote under the “fail-safe” procedures in IC 3-10-11 or 3-10-12. I am a member of the Indiana National Guard deployed or on assignment in Indiana or a public safety officer. NOTE: UOCAVA voters should use the Federal Post Card Application (FPCA) instead of the ABS-Mail form, if qualified to do so. I am a “serious sex offender” (as defined in IC 35-42-4-14(a)). I am prevented from voting due to the unavailability of transportation to the polls. Contact your county election board if you wish to vote by absentee ballot in person at the clerk’s office or other satellite location or before a bi-partisan traveling board team; you want your power of attorney to apply for you; or are in Attorney General Confidentiality Program. I swear or affirm under the penalties of perjury that all information set forth on this application is true to the best of my knowledge and belief. Perjury is punishable by imprisonment for up to 2½ years, a fine of up to $10,000, or both. Signature of voter (or person designated to sign by a voter with disabilities who is unable to sign) X Date signed (mm/dd/yy) / / 5. IF YOU RECEIVED THIS COMPLETED APPLICATION FROM THE VOTER, PUT THE DATE IT WAS RECEIVED: , 20 . 6. INFORMATION OF INDIVIDUAL ASSISTING ABSENTEE BALLOT APPLICANT Name (Please print.) Date of birth (mm/dd/yy) / / Telephone Number (Day) ( ) Telephone Number (Evening) ( ) Registration Address (number and street) City/Town, State, ZIP Code Mailing Address (number and street) City/Town, State, ZIP Code I swear or affirm under penalties of perjury that I am not the employer of this voter, an officer of the voter’s union, or an agent of the employer or union of this voter and have no knowledge or reason to believe that the individual submitting the application: is ineligible to vote or to cast an absentee ballot; or did not properly complete and sign the application. Signature of Person Assisting Voter with Application X Date signed (mm/dd/yy) / / FOR OFFICE USE ONLY Date (mm/dd/yy) / / Precinct Is applicant required to provide additional documentation to the county voter registration office but has not yet done so? Yes No Reset Form ---PAGE BREAK--- Indiana County Offices Complete and sign this absentee ballot application and mail it to the county where you are registered to vote or to the Indiana Election Division. INDIANA ELECTION DIVISION 302 West Washington Street, Suite 204 Indianapolis, IN 46204-2767 Phone: (317) 232-3939 Fax: (317) 233-6793 ADAMS Adams County Circuit Court Clerk 112 S 2nd St Rm A Decatur, IN 46733-1618 (260) 724-5300 ext. 2104 ALLEN Allen Co. Election Board 1 East Main Street, Suite 172 Ft. Wayne, IN 46802 (260) 449-7329 BARTHOLOMEW Bartholomew County Clerk P.O. Box 924 Columbus, IN 47202 (812) 379-1604 BENTON Benton Co. Circuit Court Clerk 706 E. 5th Street, Suite 37 Fowler, IN 47944-1556 (765) 884-0930 BLACKFORD Blackford Co. Circuit Court Clerk 110 West Washington Street Hartford City, IN 47348-2298 (765) 348-7217 BOONE Boone Co. Circuit Court Clerk 212 Courthouse Square Lebanon, IN 46052-2126 (765) 482-3510 BROWN Brown County Election Board P.O. Box 85 Nashville, IN 47448 (812) 988-5510 CARROLL Carroll County Election Board 101 W. Main Street, Ste. 206 Delphi, IN 46923 (765) 564-6795 CASS Cass Co. Circuit Court Clerk 200 Court Park, Room 407 Logansport, IN 46947-1392 (574) 753-7870 CLARK Clark Co. Circuit Court Clerk 501 E. Court Avenue, Room 139 Jeffersonville, IN 47111 (812) 285-6329 CLAY Clay County Election Office 609 E. National Ave., Room 213 Brazil, IN 47834 (812) 448-9023 CLINTON Clinton Co. Circuit Court Clerk 265 Courthouse Square Frankfort, IN 46041-1993 (765) 659-6337 CRAWFORD Crawford Co. Circuit Court Clerk 715 Judicial Plaza Drive P.O. Box 375 English, IN 47118 (812) 338-2565 DAVIESS Daviess Co. Circuit Court Clerk P.O. Box 739 Washington, IN 47501-0739 (812) 254-8679 DEARBORN Dearborn County Election Clerk 165 Mary Street Lawrenceburg, IN 47025 (812) 537-8867 DECATUR Decatur Co. Circuit Court Clerk 150 Courthouse Square, Suite 244 Greensburg, IN 47240-2080 (812) 663-8223 DEKALB DeKalb Co. Circuit Court Clerk 100 S. Main Street P.O. Box 230 Auburn, IN 46706-0230 (260) 925-9787 DELAWARE Delaware County Clerk (Election Room) 100 W. Main Street, Room 100 Muncie, IN 47305 (765) 747-7764 DUBOIS Dubois Co. Circuit Court Clerk One Courthouse Square Jasper, IN 47546-3058 (812) 481-7035 ELKHART Elkhart Co. Election Board 101 North Main Street, Rm 204 Goshen, IN 46526 (574) 535-6469 FAYETTE Fayette Co. Circuit Court Clerk 401 Central Avenue Connersville, IN 47331 (765) 825-1813 FLOYD Floyd Co. Circuit Court Clerk 311 Hauss Square, Rm. 235 New Albany, IN 47150-3584 (812) 948-5415 FOUNTAIN Fountain Co. Circuit Court Clerk 301 4th St, P.O. Box 183 Covington, IN 47932 (765) 793-6230 FRANKLIN Franklin Co. Circuit Court Clerk 459 Main Street Brookville, IN 47012-1486 (765) 647-5111 ext. 3 FULTON Fulton County Voter Registration 815 Main Street, Rm 211 Rochester, IN 46975 (574) 223-7713 GIBSON Gibson Co. Circuit Court Clerk 101 N. Main St. Princeton, IN 47670 (812) 385-2541 GRANT Grant Co. Circuit Court Clerk Courthouse Suite B-9 101 E. 4th Street Marion, IN 46952 (765) 664-9880 GREENE Greene County Voter Registration P.O. Box 229 Bloomfield, IN 47424-0229 (812) 384-2015 HAMILTON Hamilton County Election OFfice One Hamilton County Square, Suite 106 Noblesville, IN 46060-2233 (317) 776-8476 HANCOCK Hancock County Election Office 9 East Main Street Greenfield, IN 46140 (317) 477-1171 HARRISON Harrison Co. Circuit Court Clerk Courthouse, Room 203 300 North Capitol Avenue Corydon, IN 47112-1155 (812) 738-4289 HENDRICKS Hendricks Co. Voter Registration Office 355 S. Washington St. #120 Danville, IN 46122 (317) 745-9249 HENRY Henry County Voter Registration Office 1215 Race St, Suite 130 New Castle, IN 47362 (765) 529-9310 HOWARD Howard County Clerk of Elections120 E Mulberry St., Room 102 Kokomo, IN 46901 (765) 614-3220 HUNTINGTON Huntington Co. Circuit Court Clerk 201 North Jefferson Street P.O. Box 228 Huntington, IN 46750 (260) 358-4820 JACKSON Jackson Co. Voter Registration 109 S Sugar St, Suite 130 Brownstown, IN 47220 (812) 358-6120 JASPER Jasper County Clerk 115 W. Washington, Suite 204 Rensselaer, IN 47978 (219) 866-4929 JAY Jay Co. Circuit Court Clerk 120 North Court Street, Ste. 209 Portland, IN 47371 (260) 726-4951 JEFFERSON Jefferson County Voter Registration Courthouse, Room 203 300 E. Main Street Madison, IN 47250-3594 (812) 265-8926 JENNINGS Jennings County Election Office P.O. Box 385 Vernon, IN 47282-0385 (812) 352-3080 JOHNSON Johnson Co. Voter Registration P.O. Box 451 Franklin, IN 46131-0451 (317) 346-4467 KNOX Knox County Voter Registration 111 N. 7th Street, Suite 27 Vincennes, IN 47591-2022 (812) 895-4927 KOSCIUSKO Kosciusko Co. Circuit Court Clerk 121 N. Lake Street, D162 Warsaw, IN 46580-2788 (574) 372-2332 LAGRANGE LaGrange County Voter Registration 105 North Detroit Street LaGrange, IN 46761-1801 (260) 499-6392 LAKE Lake Co. Board of Eletions & Registration 2293 N. Main Street, A-205 Crown Point, IN 46307 (219) 755-3795 LA PORTE La Porte County Election Board 813 Lincolnway, Suite 105 La Porte, IN 46350 (219) 326-6808 ext. 2266 LAWRENCE Lawrence Co. Clerk/Voter Registration Courthouse Plaza 918 16th Street, Ste. 200 Bedford, IN 47421 (812) 277-2036 MADISON Madison Co. Circuit Court Clerk P.O. Box 1277 Anderson, IN 46015 (765) 641-9459 MARION Marion Co. Election Board 3737 E. Washington St. Indianapolis, IN 46201 (317) 327-5100 MARSHALL Marshall Co. Circuit Court Clerk 211 West Madison Street Plymouth, IN 46563-1762 (574) 935-8713 MARTIN Martin Co. Circuit Court Clerk 129 Main Street P.O. Box 120 Shoals, IN 47581 (812) 247-3651 MIAMI Miami County Voter Registration 25 N. Broadway, Room 108 Peru, IN 46970-0184 (765) 472-3995 MONROE Monroe Co. Voter Registration 401 W. 7th Street, Suite 100 Bloomington, IN 47404 (812) 349-2690 MONTGOMERY Montgomery Co. Circuit Court Clerk P.O. Box 768 Crawfordsville, IN 47933 (765) 364-6437 MORGAN Morgan County Election Division 180 S. Main St., Suite 1 Martinsville, IN 46151 (765) 342-1029 NEWTON Newton Co. Circuit Court Clerk P.O. Box 49 Kentland, IN 47951-0049 (219) 474-6081 NOBLE Noble Co. Circuit Court Clerk 101 North Orange Street Albion, IN 46701-1092 (260) 636-2736 ext. 1806 OHIO Ohio Co. Circuit Court Clerk P.O. Box 185 Rising Sun, IN 47040-0185 (812) 438-2610 ORANGE Orange Co. Circuit Court Clerk Orange County Courthouse 1 Court Street Paoli, IN 47454-9632 (812) 723-2649 OWEN Owen Co. Circuit Court Clerk 60 S. Main St. Spencer, IN 47460- 0146 (812) 829-5028 PARKE Parke Co. Circuit Court Clerk 116 West High St., Room 204 Rockville, IN 47872-1781 (765) 569-5132 PERRY Perry Co. Circuit Court Clerk 2219 Payne Street Tell City, IN 47586-2832 (812) 547-3741 PIKE Pike Co. Circuit Court Clerk 801 Main St., P.O. Box 125 Petersburg, IN 47567 (812) 354-6025 PORTER Porter Co. Board of Elections and Registration 155 Indiana Avenue, Ste. 105 Valparaiso, IN 46383-5555 (219) 465-3485 / (219) 465-3398 POSEY Posey Co. Circuit Court Clerk 300 Main Street, Rm 115 Mt. Vernon, IN 47620-0606 (812) 838-1339 PULASKI Pulaski Co. Circuit Court Clerk 112 E. Main Street, Room 230 Winamac, IN 46996-1394 (574) 946-4401 PUTNAM Putnam County Voter Registration 1 W. Washington St., Room 21, P.O. Box 546 Greencastle, IN 46135-0546 (765) 653-1538 RANDOLPH Randolph Co. Circuit Court Clerk 100 S. Main St., Room 201 Winchester, IN 47394 (765) 584-4717 RIPLEY Ripley Co. Circuit Court Clerk 115 N. Main Street P.O. Box 177 Versailles, IN 47042 (812) 689-6115 RUSH Rush County Voter Registration 101 East 2nd Street, Rm 209 Rushville, IN 46173 (765) 932-2086 SCOTT Scott County Voter Registration 1 East McClain Avenue, Suite 120 Scottsburg, IN 47170 (812) 752-8420 SHELBY Shelby Co. Circuit Court Clerk 407 S. Harrison Street P.O. Box 198 Shelbyville, IN 46176 (317) 392-6324 SPENCER Spencer County Voter Registration 200 Main Street, Ste. 5 P.O. Box 523 Rockport, IN 47635 (812) 649-6029 ST. JOSEPH St. Joseph Co. Circuit Court Clerk 101 S Main St South Bend, IN 46601 (574) 235-9635 STARKE Starke County Voter Registration 53 East Washington Street P.O. Box 395 Knox, IN 46534 (574) 772-9160 STEUBEN Steuben Co. Circuit Court Clerk 55 South Public Square Angola, IN 46703-1945 (260) 668-1000 EXT 2220 SULLIVAN Sullivan Co. Circuit Court Clerk 100 Courthouse Square, P.O. Box 370 Sullivan, IN 47882-0370 (812) 268-4657 SWITZERLAND Switzerland Co. Circuit Court Clerk Courthouse 212 West Main Street Vevay, IN 47043-1180 (812) 427-4415 TIPPECANOE Tippecanoe Co. Board of Elections & Registration 20 N. 3rd Street P.O. Box 619 Lafayette, IN 47902 (765) 423-9316 TIPTON Tipton Co. Circuit Court Clerk 101 East Jefferson Street Tipton, IN 46072-1901 (765) 675-2795 UNION Union Co. Circuit Court Clerk 26 West Union Street Liberty, IN 47353-1396 (765) 458-6121 VANDERBURGH Vanderburgh County Election Office P.O. Box 3343 Evansville, IN 47732-3343 (812) 435-5123 VERMILLION Vermillion Co. Circuit Court Clerk P.O. Box 10 Newport, IN 47966 (765) 492-5350 VIGO Vigo Co. Circuit Court Clerk 33 South 3rd Street Terre Haute, IN 47807 (812) 462-3235 WABASH Wabash Co. Circuit Court Clerk 69 West Hill Street Wabash, IN 46992 (260) 563-0661 EXT 1238 WARREN Warren County Voter Registration 125 N. Monroe Street, Suite 11 Williamsport, IN 47993-1198 (765) 762-2834 WARRICK Warrick Co. Election Office 1 County Square, Suite 220 Boonville, IN 47601 (812) 897-6161 WASHINGTON Washington County Justice Center 801 S. Jackson St, Suite 102 Salem, IN 47167 (812) 883-5748 EXT 1128 WAYNE Wayne County Voters Registration 301 E. Main Street Richmond, IN 47374 (765) 973-9304 WELLS Wells Co. Clerk 102 W. Market St., Suite 201 Bluffton, IN 46714-2091 (260) 824-6479 WHITE White Co. Circuit Court Clerk 110 Main Street P.O. Box 350 Monticello, IN 47960-0350 (574) 583-1531 WHITLEY Whitley Co. Circuit Court Clerk 101 W. Van Buren Street Columbia City, IN 46725-2087 (260) 248-3164