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APPLICATION FOR ABSENTEE BALLOT BY TRAVELING BOARD for Election on (ABS-TRAVELING BOARD) State Form 55379 (R5 / 3-22) INDIANA ELECTION DIVISION (IC 3-11-4-2; 3-11-4-5.1; 3-11-4-6; 3-11-10-24; 3-11-10-25) FOR COUNTY ELECTION BOARD USE ONLY Precinct ADDITIONAL DOCUMENTATION Is applicant required to provide additional residence documentation to the county voter registration office but has not yet done so? Yes No INSTRUCTIONS FOR VOTER: The voter (or a person designated by a voter with disabilities who is unable to sign) must SIGN the application below. If you are applying as the voter’s attorney in fact, a copy of the power of attorney must be attached to this application. Some voters who have registered for the first time in Indiana, and did so by mail, are required to provide additional residence documents. The county election board can tell you if this requirement applies to you. Use this application to vote your absentee ballot before a bipartisan traveling board. If you are asking that an absentee ballot be sent to you by mail and you are able to personally mark your own ballot without assistance or are a voter with print disabilities who may have assistance in completing their ballot by any person other than their employer, union representative, or agent of the employer or union, use form ABS-MAIL. If you are a member of the Attorney General’s address confidentiality program, use form ABS-ATTORNEY GENERAL. If you are an overseas voter or uniformed services (military) voter, use the FPCA (Federal Postcard Application) form. A voter with print disabilities is entitled to vote using a system developed by the Secretary of State which makes web content for voting by absentee ballot accessible to the voter, and is not required to submit an application for voting an absentee ballot by traveling board. This form must be received by noon the day before the election and may be hand delivered, mailed, e-mailed, or faxed. If you receive this completed absentee application from a voter, you must file this completed application with the county or Indiana Election Division by noon, 10 days after receiving it or by the absentee deadline, whichever comes first. You must also provide the date you received the completed application in box 3. Unless you are filing this form electronically online through indianavoters.com, you do not need to provide a telephone number. However, the county election board must be able to contact the voter to schedule a mutually agreeable time for the traveling board to visit. Providing a phone number (or email address) is the quickest way for this appointment to be scheduled. 1. INFORMATION OF ABSENTEE BALLOT APPLICANT Name (please print) Date of Birth (mm/dd/yy) Last Four Digits of Social Security Number (Optional) OR I do not have a Social Security Number. Registration Address (number and street) City/Town, State, ZIP Code Please have the traveling board visit me at the following address: (number and street, city/town, state, and ZIP code) 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 record.) Telephone Number (Optional, if not filing online) E-mail Address (Optional) I qualify to vote by traveling board because (select at least one): of illness or injury; of caring for a confined person at a private residence; OR I am a voter with disabilities and believe that my polling place is not accessible to me. If applicable, I request that the county election board authorize the traveling board to visit me at this location, which is outside of the county where I am registered to vote. Approved by County Election Board Denied by County Election Board 2. COMPLETE THIS SECTION OF APPLICATION TO VOTE IN PRIMARY Under state law, you must request a major political party ballot to vote in the 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 (check one box): Democratic Party Republican Party OR I do not wish to vote in either political party’s primary, but wish to vote on a Public Question Only I swear or affirm under the penalties of perjury that all of the information set forth on this application is true, to the best of my knowledge and belief. Signature of voter (or person designated to sign by a voter with disabilities who is unable to sign) X Date signed (month, day, year) 20__ 3. IF YOU RECEIVED THIS COMPLETED APPLICATION FROM THE VOTER, PUT THE DATE IT WAS RECEIVED: Date Person Received This Application from Applicant: 20__ 4. INFORMATION OF INDIVIDUAL ASSISTING ABSENTEE BALLOT APPLICANT Name (please print) Date Assistance to Applicant Provided 20__ Residence Address (number and street) City/Town, State, ZIP Code Telephone Number (Day) ( ) Mailing Address (number and street) (If different from residence address) City/Town, State, ZIP Code Telephone Number (Evening) ( ) I swear or affirm under the 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 Date signed (month, day, year) 20__ Penalty for perjury: A person who makes a false, material statement under oath or affirmation, knowing the statement to be false or not believing it to be true commits perjury, a Level 6 felony, punishable by imprisonment for up to 2 ½ years, a fine of up to $10,000, or both. SIGN SIGN