APPLICATION FOR ABSENTEE BALLOT

(Return completed form to municipal clerk.)

1. ALL PERSONS REQUESTING AN ABSENTEE BALLOT MUST COMPLETE THIS SECTION AND SIGN IN SECTION 4 BELOW:

I request that an absentee ballot be sent to me for the Primary to be held on _____________________________________________________, ___________.

and for the Election to be held on _______________________________________________________, ___________.

I certify that I am a United States Citizen, age 18 or older, and that I have resided at the following address which is my legal voting address for at least 10 days before the election for which I am applying for an absentee ballot.

Street and number, if any ______________________________________________________ Municipality _______________________________________

Mail/Deliver Ballot to:

Name __________________________________________________________ Nursing Home _________________________________________________

Street and number, if any __________________________________________________________________________________________________________

Municipality _____________________________________________________ State _____________________________ Zip ________________________

Please sign your name in Section 4.

**If you are an indefinitely confined elector requesting an automatic ballot for each election, please go to Section 2. If you are a hospitalized elector requesting an absentee ballot by agent, go to Section 3.

2. INDEFINITELY CONFINED ABSENTEE ELECTOR REQUESTING AN AUTOMATIC BALLOT FOR EACH ELECTION MUST CHECK THE BOX BELOW:

q I further certify that I am indefinitely confined because of age (at least 70 years old), illness, infirmity or disability. I request that an absentee ballot be automatically provided for every election until such time as I notify you or until such time as I fail to return an absentee ballot.

Please sign your name in Section 4.

3. HOSPITALIZED ELECTOR REQUESTING AN ABSENTEE BALLOT BY AGENT MUST CHECK THE BOX AND COMPLETE THE FOLLOWING:

q I certify that I cannot appear at the polling place on election day because I am hospitalized.

I appoint _____________________________________________________________________ to serve as my agent, pursuant to s.6.86(3), Wis. Stats.

WITNESS

I certify that I am a resident of this absentee elector’s municipality, and that the statements contained in this application are true to the best of my knowledge.

Signed________________________________________________________ Address _______________________________________________________

(Signature of Witness)

AGENT

I certify that I am the duly appointed agent of the hospitalized absentee elector, that the absentee ballot to be received by me is received solely for the benefit of the above named hospitalized elector, and that such ballot will be promptly transmitted by me to that elector and then returned to the municipal clerk or the proper polling place.

Signed ________________________________________________________ Address ________________________________________________________

(Signature of Agent)

Hospitalized elector, please sign your name in Section 4.

4. ALL REQUESTS MUST BE SIGNED BY ELECTOR.

SIGNATURE OF ELECTOR REQUESTING ABSENTEE BALLOT: ___________________________________________________________________

FOR OFFICE USE

Registered Ward Aldermanic District School District ____________

Congressional District Assembly District County Supervisor District ______________

EB-121 (Rev 6/00) The information on this form is required by ss.6.85, 6.86, 6.87, Wis. Stats. Providing false information on this form is punishable by a fine of $1,000, imprisonment of six months or both ss.12.13(3)(i), 12.60(1)(b), Wis. Stats. This form is prescribed by the State Elections Board, 132 East Wilson Street, Suite 200, P.O. Box 2973, Madison, WI 53701-2973. (608) 266-8005.