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Please print clearly. Be sure to complete all required sections. Brad Raffensperger Secretary of State The information provided in this document is made under oath and penalty of law and will be used for official government purposes. When you sign this application, you affirm that you are a citizen of the U.S., currently reside in Georgia and are eligible to vote in Georgia. Giving false information on this application violates Georgia law and is punishable by a fine up to $100,000, imprisonment for up to 10 years, or both. Your name as it appears on your voter registration. The residential or mailing address on your voter registration. If you no longer reside at the address where you are registered to vote, contact your county election office prior to submitting this application. The application must be received by your election office* 11 days before the election. Application for Georgia Official Absentee Ballot 2 6 1 Print voter name Required Contact information Recommended Date of Election Required Last Date of Primary, Election, or Runoff (mm/dd/yyyy) Suffix First Phone number Middle Email address 7 Voter identification Required Print carefully. This information will be used to verify your identity. Failure to provide accurate information may delay processing your application. You must provide your date of birth AND • a Georgia Driver’s License or Identification Card number OR • a copy of an acceptable identification from the list in the instructions. 4 5 Residential address Required Your ballot will be sent here unless you provide a temporary mailing address. Temporary ballot mailing address Only if you are temporarily living outside the county** and want your ballot sent to this address. Address City GA Zip County If you received this application with your information pre-filled, received multiple or duplicate copies of this application in the mail after you have already requested, received, or voted an absentee ballot , or if an unauthorized person offers to return your absentee ballot application, please report this to [EMAIL REDACTED]. 8 Voter oath and signature Required Use a pen. No electronic signatures allowed. I, the undersigned, do swear and affirm that I am eligible to vote in Georgia, am a citizen of the U.S. and the facts presented in this application are true. By signing this oath, you are swearing that you are the voter requesting an absentee ballot. Signing this oath on behalf of another voter violates Georgia law and is punishable by a fine up to $100,000, imprisonment for up to 10 years, or both. Voter, sign and date here (Required) X Instructions: • Make sure your identification on your ID card or document is visible. • Take a photo of your full completed application and submit it electronically to your elections office* (addresses are online: mvp.sos.ga.gov/s/county-election- offices). You may also submit a hard copy of your application via U.S. mail or in person to your elections office*. • If your acceptable form of identification does not fit in this box, please attach a copy and submit it with your application. Date of birth (mm/dd/yyyy) This address must be in a different county** than the one where you are registered unless you are physically disabled or detained in jail or other detention facility. Address City Zip State Georgia Driver’s License Number or State Identification Card Number I do not have a Georgia Driver’s License or Identification Card and I am providing a copy of acceptable identification below. Place identification here if you did not provide a Georgia driver’s license or ID number OR Date (mm/dd/yyyy) AND Form continues ► APP-21_V3(2023) 3 Type of ballot Required in primary Democratic Republican Non Partisan (will not have ANY party candidates listed) Pursuant to O.C.G.A §21-2-381(a)(1)(c)(iii). , Third-Party Distributors: List name and address before distributing this form. This application is being distributed by not by any government agency or any state or local election office. THIS IS NOT A BALLOT. ---PAGE BREAK--- Brad Raffensperger Secretary of State Ballot to be: Application for Georgia Official Absentee Ballot 11 Requesting a ballot on behalf of a voter? If yes, complete this section. The voter must be physically disabled or temporarily residing out of the county** and must still be eligible to vote in the county** where he or she is registered. Relationship to voter Dist. Combo Received GA DL Precinct ISS Other Ballot # Certified Voter Reg # Rejected Email 12 Ballot request opt-in Optional If you meet the eligibility criteria, you may opt-in to receive an absentee ballot for the rest of the elections cycle without making another application. 10 Assisting a voter? If yes, the assistant must complete this section. Voter assistance is only allowed if the voter is illiterate or physically disabled. I opt-in to receive an absentee ballot for the rest of the election cycle. physically disabled temporarily residing out of the county** is eligible is not eligible D- Disabled. I am physically disabled E- Elderly. I am 65 years of age or older U- UOCAVA. I am a uniformed service member, spouse or dependent of a uniformed service member, or other US citizen residing overseas. (Complete the information to the right) MOS - Military Overseas MST - Military Stateside OST - Overseas Temporary Resident OSP - Overseas Permanent Resident (may vote for federal offices only) Mailed electronically Delivered to voter in hospital by Registrars or Deputy Voted in office (municipal only) Acceptable forms of identification if you do not have a Georgia Driver’s License or State Identification Card Number Identification with your photograph: • United States Passport • Georgia voter identification card • Other valid identification card issued by a branch, department, agency, or entity of the State of Georgia, any other state, or the United States authorized by law to issue personal identification • United States military identification card • Employee identification card issued by any branch, department, agency, or entity of the United States government, Georgia state government, or Georgia county, municipality, board, authority, or any other entity of the state of Georgia • Tribal identification card Documents that show your name and address: • Current utility bill • Bank statement • Paycheck • Government check • Other government document How to return your absentee ballot application Absentee ballot applications must be received 11 days before the date of the election. You can return the form by: • mail • email (as an attachment) • fax • in-person at your elections or registrar’s office Your County Board of Registrar’s Office information can be found online: *In state, county, and federal elections, your elections office is your county elections office. In municipal elections, your elections office is your municipal elections office. **Or, in municipal elections, municipality. No person or entity other than the elector, a relative authorized to request an absentee ballot for such elector, a person signing as assisting an illiterate or physically disabled elector with his or her application, a common carrier charged with returning the ballot application, an absentee ballot clerk, a registrar, or a law enforcement officer in the course of an investigation shall handle or return an elector’s completed absentee ballot application. Handling a completed absentee ballot application by any person or entity other than as allowed in this paragraph is a misdemeanor. Assistant’s signature Date (mm/dd/yyyy) X I swear that the facts contained in this application are true and that I am either the mother, father, grandparent, brother, sister, aunt, uncle, spouse, son, daughter, niece, nephew, grandchild, son-in-law, daughter-in-law, mother-in-law, father-in-law, brother-in-law or sister-in-law of the age of 18 and acknowledge that making a false statement on this application regarding my relationship to the voter violates Georgia law and is punishable by a fine up to $1,000, 12 months in jail, or both. By signing as assisting the voter, you are swearing under oath that the voter is entitled to assistance. Assisting a voter who is not eligible for assistance in completing this application violates Georgia law and is punishable by a fine up to $100,000 or imprisonment for up to 10 years, or both. I swear (or affirm) that the above-named voter is: (check one) I certify that the above named voter I am eligible for the reason selected below: Ballot Dates ID Shown For office use only UOCAVA Voters only My current status is (check one) (Optional) By entering my email, I request that my absentee ballot be transmitted to me electronically. Assistant’s name Signature of authorized and eligible requestor X Registrar signature Your name as it appears on your voter registration. 9 Print voter name Required Last Suffix First Middle Pursuant to O.C.G.A §21-2-381(a)(1)(c)(iii). , Third-Party Distributors: List name and address before distributing this form. This application is being distributed by not by any government agency or any state or local election office. THIS IS NOT A BALLOT.