Transcription of County Election Office Ballot Application
1 32-941 Updated August 2018 Nebraska early voting Ballot Application Date: _____ I, the undersigned, declare that I am a registered voter in Nebraska. I am registered at the following address: _____, in _____ County . I am requesting early voting ballots for the following Election : Primary General Special (*The first day to request an early voting Ballot is 120 days before an Election ) to be held on _____ _____, 20_____. I request to vote in the Election Office today as the early voting Polling Place.
2 I request that ballots be mailed to me, (or to the person I am acting as agent for), at the following address: Address Line 1: _____ Address Line 2: _____ City, State, Zip: _____ I request to take the ballots with me, (or to the person I am acting as agent for, up to two people). To confirm any information prior to sending the ballots, the Election Office may reach me at: Phone: _____ Email: _____ Voter s Printed Name: _____ Voter s Signature: _____ Voter s Date of Birth (MM/DD/YYYY) ____ /____ /_____ If applying for another voter: Agent s Signature: _____ Relationship: _____ Election falsification is a Class IV felony and may be punished by up to two years imprisonment and twelve months post-release supervision, a fine of up to ten thousand dollars, or both.
3 Election Office Use Only Application Number: _____ Date Received: _____ Date Sent: _____ Voter ID Number: _____ Ballot Assigned: _____ Staff initials: _____ Return completed Application to: _____ County Election Office _____ _____, NE _____
