Full Text
Application for Absentee Ballot Including Request for Absentee Ballot due to Illness or Health Emergency FOR FILING OFFICE ONLY Precinct Ballot By Issuing Official or Special Absentee Board Ballot voted in office Ballot picked up by voter Ballot mailed to voter Ballot picked up by third party Ballot delivered by special absentee board (members sign above) SUBMIT COMPLETED FORM NO SOONER THAN 75 DAYS BEFORE THE ELECTION AND NO LATER THAN NOON THE DAY BEFORE THE ELECTION. Elector Name County where registered Residence address in said County Street/Other City Zip I hereby request an absentee ballot for the: Primary General Municipal Other election to be held on Month/Day Year Address where ballot will be Street/PO Box/Other City Zip By signing below, I understand that I am officially requesting an 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 sos.mt.gov) Please send current Voter Information Pamphlet, if applicable to this election Optional - Annual Absentee List – By checking one of the boxes below, I understand that I will be mailed an absentee ballot for applicable elections that I am qualified to vote in, as long as I reside at the address listed above, and as long as I complete and return a confirmation notice mailed to me by the county election office each year in January. I UNDERSTAND I MUST COMPLETE AND RETURN AN ANNUAL ADDRESS CONFIRMATION NOTICE TO REMAIN ON THE ABSENTEE LIST. All elections All federal elections only Optional - Designation of another person to pick up absentee ballot I, the elector who signed above, hereby designate to pick up my absentee ballot. Optional - Receipt of absentee ballot by designee On this of I received the absentee ballot for the applicant named above. Signature of designee Date WHERE TO RETURN VOTED BALLOT AFFIDAVIT OF ELECTOR (DUE TO ILLNESS OR HEALTH EMERGENCY) Return voted absentee ballots to your county election office no later than close of polls on election day, or to your polling place on election day. County election office address: Ballots mailed to the county election office must be received no later than 8:00 p.m. on election day. 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 noon on election day. Signature of Elector and Date Signed ---PAGE BREAK--- Montana Secretary of State Linda McCulloch - County Election Administrator Contact List COUNTY NAME ADDRESS CITY/STATE/ZIP PHONE FAX E-MAIL Beaverhead Debbie Scott 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 [EMAIL REDACTED] Blaine Sandra L Boardman PO Box 278 Chinook MT 59523 (406) 357-3240 (406) 357-2199 [EMAIL REDACTED] Broadwater Doug Ellis 515 Broadway St Townsend MT 59644 (406) 266-9215 (406) 266-3674 [EMAIL REDACTED] Carbon Sally A. Rodibaugh 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 [EMAIL REDACTED] Chouteau Lana K 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 Jeanne Clapp 207 West Bell Glendive MT 59330 (406) 377-3058 (406) 377-1717 [EMAIL REDACTED] Deer Lodge Joey Blodnick 800 Main Anaconda MT 59711 (406) 563-4060 (406) 563-4001 [EMAIL REDACTED] Fallon Brenda J Wood 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 Paula Robinson 800 S Main Kalispell MT 59901 (406) 758-2453 (406) 758-5877 [EMAIL REDACTED] Gallatin Charlotte Mills 311 W Main Rm 210 Bozeman MT 59715 (406) 582-3060 (406) 582-3068 [EMAIL REDACTED] Garfield Janet Sherer Box 7 Jordan MT 59337 (406) 557-2760 (406) 557-2765 [EMAIL REDACTED] Glacier Glenda Hall 512 E Main Cut Bank MT 59427 (406) 873-3609 (406) 873-3613 Golden Valley Mary Lu Berry PO Box 10 Ryegate MT 59074 (406) 568-2231 (406) 568-2428 Granite Blanche McLure Box 925 Philipsburg MT 59858 (406) 859-3771 (406) 859-3817 [EMAIL REDACTED] Hill Darla Dahl 315 4th St Havre MT 59501 (406) 265-5481 x221 (406) 265-2445 [EMAIL REDACTED] Jefferson Bonnie Ramey Box H Boulder MT 59632 (406) 225-4020 (406) 225-4149 [EMAIL REDACTED] Judith Basin Amanda H Kelly Box 427 Stanford MT 59479 (406) 566-2277 x109 (406) 566-2211 [EMAIL REDACTED] Lake Kathie Newgard 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) 447-8338 (406) 457-8598 [EMAIL REDACTED] Liberty Rhonda S Pimley Box 459 Chester MT 59522 (406) 759-5365 (406) 759-5395 [EMAIL REDACTED] Lincoln Tammy D Lauer 512 California Libby MT 59923 (406) 283-2300 (406) 293-8577 [EMAIL REDACTED] Madison Peggy Kaatz Box 366 Virginia City MT 59755 (406) 843-4270 (406) 843-5264 [EMAIL REDACTED] McCone Maridel L Kassner Box 199 Circle MT 59215 (406) 485-3505 (406) 485-2689 [EMAIL REDACTED] Meagher Dayna Ogle Box 309 White Sulphur MT 59645 (406) 547-3612 x2 (406) 547-3388 [EMAIL REDACTED] Mineral Staci Hayes Box 550 Superior MT 59872 (406) 822-3520 (406) 822-3579 [EMAIL REDACTED] Missoula Vickie Zeier 200 W Broadway Missoula MT 59802 (406) 258-4751 (406) 258-3913 [EMAIL REDACTED] Musselshell Jane E Mang 506 Main Roundup MT 59072 (406) 323-1104 (406) 323-3303 [EMAIL REDACTED] Park Denise Nelson 414 E Callender St Livingston MT 59047 (406) 222-4110 (406) 222-4193 [EMAIL REDACTED] Petroleum Leslie Mitchell Box 226 Winnett MT 59087 (406) 429-5311 (406) 429-6328 [EMAIL REDACTED] Phillips Marian Ereaux 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 Karen D Amende Box 200 Broadus MT 59317 (406) 436-2361 (406) 436-2151 [EMAIL REDACTED] Powell Diane S Grey 409 Missouri Deer Lodge MT 59722 (406) 846-9786 (406) 846-3891 [EMAIL REDACTED] Prairie Toni Kalfell 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 A Hansen 400 2nd Ave S Wolf Point MT 59201 (406) 653-6250 (406) 653-6289 [EMAIL REDACTED] Rosebud Geraldine Custer Box 47 MT 59327 (406) 346-7318 (406) 346-7551 Sanders Jennine Robbins Box 519 Thompson Falls MT 59873 (406) 827-6922 (406) 827-6970 clerk&[EMAIL REDACTED] Sheridan Mary 100 W Laurel Ave Plentywood MT 59254 (406) 765-3403 (406) 765-2609 Silver Bow Sally Hollis 155 W Granite Rm 208 Butte MT 59701 (406) 497-6342 (406) 497-6328 [EMAIL REDACTED] Stillwater Pauline M Mishler Box 149 Columbus MT 59019 (406) 322-8000 (406) 322-8069 [EMAIL REDACTED] Sweet Grass Sherry Bjorndal Box 888 Big Timber MT 59011 (406) 932-5152 (406) 932-3026 [EMAIL REDACTED] Teton Paula J Jaconetty Box 610 Choteau MT 59422 (406) 466-2693 (406) 466-3244 [EMAIL REDACTED] Toole Treva Nelson 226 1st St S Shelby MT 59474 (406) 424-8300 (406) 424-8301 Treasure Ruth L Baker Box 392 Hysham MT 59038 (406) 342-5547 (406) 342-5547 [EMAIL REDACTED] Valley Lynne Nyquist 501 Court Sq Box 2 Glasgow MT 59230 (406) 228-6226 (406) 228-9027 Wheatland Mary E Miller Box 1903 Harlowton MT 59036 (406) 632-4891 (406) 632-4880 [EMAIL REDACTED] Wibaux Patricia Zinda 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] 1/10/2013