Application for Ballot by Mail - co.hood.tx.us
2
DO NOT REMOVE PERFORATED TABS. PEEL TAPE HERE AND FOLD BOTTOM TO TOP TO SEAL. Application for Ballot by Mail 7 1 / 2 1 5 1 - 5 A VUID #, County Election Precinct #, Statement of Residence, etc. 1 Last Name (Please print information) (Jr., Sr., III, etc) First Name Middle Initial 2 Residence Address: See back of this application for instructions. City ,TX ZIP Code 3 Mail my ballot to: If mailing address differs from residence address, please complete Box # 7. City State ZIP Code 4 Date of Birth (mm/dd/yyyy) (Optional) Contact Information (Optional)* Please list phone number and/or email address: * 5 Reason for Voting by Mail: 65 years of age or older. (Complete Box #6a) Disability. (Complete Box #6a) Expected absence from the county. (Complete Box #6b and Box #8) You will receive a ballot for the upcoming election only (Complete Box #6b) You will receive a ballot for the upcoming election only 6a ONLY Voters 65 Years of Age or Older or Voters with a Disability: If applying for one election, select appropriate box. If applying once for elections in the calendar year, select “Annual Application.” Annual Application Uniform and Other Elections: May Election November Election Other ___ Primary Elections: You must declare one political party to vote in a primary: Democratic Primary Republican Primary Any Resulting Runoff 6b You may only apply for a ballot by mail for one election, and any resulting runoff. Please select the appropriate box. Uniform and Other Elections: May Election November Election Other ____ Primary Elections: You must declare one political party to vote in a primary: Democratic Primary Republican Primary Any Resulting Runoff 7 If you are requesting this ballot be mailed to a different address (other than residence), indicate where the ballot will be mailed. See reverse for instructions. Nursing home, assisted living facility, or long term care facility Hospital Retirement Center Address of the jail Relative; relationship _____ Address outside the county (see Box #8) 8 If you selected “expected absence from the county,” see reverse for instructions Date you can begin to receive mail at this address Date of return to residence address 9 Voters may submit a completed, signed, and scanned application to the Early Voting Clerk at: (early voting clerk’s e-mail address ) (early voting clerk’s fax) NOTE: If you fax or e-mail this form, please be aware that you must also mail the form to the early voting clerk within four business days. See “Submitting Application” on the back of this form for additional information. 10 “I certify that the information given in this application is true, and I understand that giving false information in this application is a crime.” X Date SIGN HERE If applicant is unable to sign or make a mark in the presence of a witness, the witness shall complete Box #11. If someone helped you to complete this form or mails the form for you, then that person must complete the sections below. 11 If applicant is unable to mark Box #10 and you are acting as a Witness to that fact, please check this box and sign below. If you assisted the applicant in completing this application in the applicant’s presence or e-mailed/mailed or faxed the application on behalf of the applicant, please check this box as an Assistant and sign below. * If you are acting as Witness and Assistant, please check both boxes. Failure to complete this information is a Class A misdemeanor if signature was witnessed or applicant was assisted in completing the application. X Signature of Witness /Assistant X Printed Name of Witness/Assistant Street Address Apt Number (if applicable) City State ZIP Code Witness’ Relationship to Applicant (Refer to Instructions on back for clarification) Este formulario está disponible en Español. Para conseguir la version en Español favor de llamar sin cargo al 1.800.252.8683 ________________ _________________________________________ ___________________________________ [email protected]
Transcript of Application for Ballot by Mail - co.hood.tx.us
DO NOT REMOVE PERFORATED TABS. PEEL TAPE HERE AND FOLD BOTTOM TO TOP TO SEAL.
Application for Ballot by Mail 71/21 51-5A VUID #, County Election Precinct #, Statement of Residence, etc.
1 Last Name (Please print information) (Jr., Sr., III, etc) First Name Middle Initial
2 Residence Address: See back of this application for instructions. City ,TX ZIP Code
3 Mail my ballot to: If mailing address differs from residence address, please complete Box # 7. City State ZIP Code
4 Date of Birth (mm/dd/yyyy) (Optional) Contact Information (Optional)*Please list phone number and/or email address:*
5 Reason for Voting by Mail:65 years of age or older. (Complete Box #6a)
Disability. (Complete Box #6a)
Expected absence from the county. (Complete Box #6b and Box #8)You will receive a ballot for the upcoming election only
(Complete Box #6b) You will receive a ballot for the upcoming election only
6a ONLY Voters 65 Years of Age or Older or Voters with a Disability:If applying for one election, select appropriate box. If applying once for elections in the calendar year, select “Annual Application.”
Annual Application
Uniform and Other Elections:
May Election
November Election
Other ___
Primary Elections:You must declare one political party to vote in a primary:
Democratic Primary
Republican Primary
Any Resulting Runoff
6b You may only apply for a ballot by mail for one election, and any resulting runoff.Please select the appropriate box.
Uniform and Other Elections:
May Election
November Election
Other ____
Primary Elections:You must declare one political party to vote in a primary:
Democratic Primary
Republican Primary
Any Resulting Runoff
7 If you are requesting this ballot be mailed to a different address (other than residence), indicate where the ballot will be mailed. See reverse for instructions.
Nursing home, assisted living facility, or long term care facility
Hospital
Retirement Center
Address of the jail
Relative; relationship _____
Address outside the county (see Box #8)
8 If you selected “expected absence from the county,” see reverse for instructions
Date you can begin to receive mail at this address Date of return to residence address
9 Voters may submit a completed, signed, and scanned application to the Early Voting Clerk at:
(early voting clerk’s e-mail address ) (early voting clerk’s fax)
NOTE: If you fax or e-mail this form, please be aware that you must also mail the form to the early voting clerk within four business days. See “Submitting Application” on the back of this form for additional information.
10 “I certify that the information given in this application is true, and I understand that giving false information in this application is a crime.”
X Date
SIGN HEREIf applicant is unable to sign or make a mark in the presence of a witness, the witness shall complete Box #11.
If someone helped you to complete this form or mails the form for you, then that person must complete the sections below.
11If applicant is unable to mark Box #10 and you are acting as a Witness to that fact, please check this box and sign below.
If you assisted the applicant in completing this application in the applicant’s presence or e-mailed/mailed or faxed the application on behalf of the applicant, please check this box as an Assistant and sign below.
*If you are acting as Witness and Assistant, please check both boxes. Failure to complete this information is a Class A misdemeanor if signature was witnessed or applicant was assisted in completing the application.
XSignature of Witness /Assistant
XPrinted Name of Witness/Assistant
Street Address Apt Number (if applicable) City
State ZIP Code
Witness’ Relationship to Applicant(Refer to Instructions on back for clarification)
Este formulario está disponible en Español. Para conseguir la version en Español favor de llamar sin cargo al 1.800.252.8683
_________________________________________________________ [email protected]
AFFIX LABEL HERE OR ADDRESSTO: EARLY VOTING CLERK
DO NOT REMOVE PERFORATED TABS. REMOVE TAPE AND FOLD TOP TO BOTTOM TO SEAL.
AFFIX FIRST CLASS
POSTAGEFROM: _________________________________
_________________________________
_________________________________
Inst
ruct
ions
for A
pplic
atio
n fo
r Bal
lot b
y M
ail
Resi
denc
e Ad
dres
s ha
ve m
oved
with
in th
e co
unty
but
not
yet
cha
nged
you
r vot
er re
gist
ratio
n ad
dres
s w
ith th
e vo
ter
regi
stra
r, in
dica
te y
our n
ew re
side
nce
addr
ess.
Mai
l Bal
lot T
o - G
ive
full a
ddre
ss w
here
you
wis
h to
hav
e ba
llot m
aile
d, if
the
addr
ess
is d
iffer
ent
from
you
r res
iden
ce a
ddre
ss.
Mai
ling
Ballo
t to
a Di
ffere
nt A
ddre
ss -
Your
bal
lot m
ust b
e m
aile
d to
you
r hom
e w
here
you
live
Rea
son
for v
otin
g by
mai
l Lo
catio
n to
mai
l bal
lot
65 o
r dis
able
d N
ursi
ng h
ome,
ass
iste
d liv
ing/
retir
emen
t cen
ter,
rela
tive,
ho
spita
l In
jail
Add
ress
of j
ail o
r rel
ativ
e A
bsen
t fro
m c
ount
y A
ddre
ss lo
cate
d ou
tsid
e of
cou
nty
Expe
cted
Abs
ence
from
Cou
nty
- If y
ou ch
ose
expe
cted
abs
ence
from
coun
ty, yo
u m
ust e
xpec
t to
be
abse
nt fr
om th
e co
unty
on
elec
tion
day
and
durin
g th
e ho
urs
of e
arly
vot
ing
in p
erso
n or
fo
r the
rem
aind
er o
f the
ear
ly v
otin
g pe
riod
afte
r you
sub
mit
your
app
licat
ion.
You
r bal
lot m
ust
be m
aile
d to
an
addr
ess
outs
ide
the
coun
ty. I
mpo
rtant
: Giv
e da
te y
ou c
an b
egin
to re
ceiv
e m
ail a
t the
add
ress
giv
en.
Annu
al A
pplic
atio
n - I
f you
are
65
year
s of
age
or o
lder
, or d
isab
led
you
may
app
ly to
rece
ive
all
ballo
ts b
y m
ail f
or a
cal
enda
r yea
r. If
you
do n
ot s
elec
t any
ele
ctio
ns in
Box
6a,
you
r app
licat
ion
will
be c
onsi
dere
d an
Ann
ual A
pplic
atio
n. If
you
sub
mit
an a
nnua
l app
licat
ion
for a
bal
lot b
y m
ail,
vote
r. Th
is m
eans
that
you
may
rece
ive
a ba
llot f
or th
ose
elec
tions
in a
dditi
on to
the
ballo
t(s)
you
requ
este
d w
ith th
is a
pplic
atio
n.
Subm
ittin
g A
pplic
atio
n1.
Sig
n an
d da
te y
our a
pplic
atio
n - I
f una
ble
to s
ign,
ple
ase
go to
Witn
ess/
Addr
ess
boxe
s (1
1 on
reve
rse)
and
hav
e a
pers
on w
itnes
s yo
ur m
ark.
Witn
ess/
Assi
stan
t ins
truct
ions
follo
w b
elow
.
2. D
eliv
er to
Ear
ly V
otin
g Cl
erk
- You
may
sub
mit
your
app
licat
ion
via
thes
e m
etho
ds:
In P
erso
n: O
nly
the
appl
ican
t may
sub
mit
thei
r app
licat
ion
in p
erso
n to
the
Early
Vot
ing
Cle
rk
until
the
early
vot
ing
perio
d be
gins
. How
ever
, afte
r the
ear
ly v
otin
g pe
riod
begi
ns fo
r an
elec
tion,
th
e ap
plic
ant m
ay o
nly
subm
it th
eir a
pplic
atio
n vi
a m
ail,
com
mon
con
tract
car
rier,
fax,
or e
-mai
l.
By M
ail:
Y ou
may
mai
l you
r app
licat
ion
via
the
U.S
. Pos
tal S
ervi
ce.
By C
omm
on C
ontra
ct C
arrie
r: Yo
u m
ay s
ubm
it vi
a a
com
mon
or c
ontra
ct c
arrie
r whi
ch is
a b
ona
By F
ax: Y
ou m
ay fa
x yo
ur a
pplic
atio
n to
the
Early
Vot
ing
Cle
rk. P
leas
e co
ntac
t you
r Ear
ly V
otin
g
By E
-Mai
l: You
may
e-m
ail a
sig
ned,
sca
nned
imag
e of
you
r app
licat
ion
to th
e Ea
rly V
otin
g C
lerk
.
IF Y
OU
FAX
OR
E-M
AIL
YOUR
APP
LICA
TIO
N TO
THE
EAR
LY V
OTI
NG C
LERK
, YO
U M
UST
ALSO
MAI
L TH
E AP
PLIC
ATIO
N SO
THA
T TH
E CL
ERK
RECE
IVES
IT N
O L
ATER
THA
N TH
E FO
URTH
BUS
INES
S DA
Y AF
TER
THE
DAY
THE
CLER
K RE
CEiV
ED Y
OUR
FAX
ED O
R EM
AILE
D AP
PLIC
ATIO
N. If
you
fax
or e
-mai
l you
r app
licat
ion
by th
e de
adlin
e no
ted
belo
w,
your
app
licat
ion
will
be
cons
ider
ed c
ompl
ete
and
timel
y as
long
as
the
orig
inal
is re
ceiv
ed
by th
e ea
rly v
otin
g cl
erk
by th
e fo
urth
bus
ines
s da
y af
ter i
t was
sub
mitt
ed b
y fa
x or
e-m
ail.
Dea
dlin
eYo
ur a
pplic
atio
n m
ust b
e re
ceiv
ed b
y th
e ea
rly v
otin
g cl
erk
of th
e lo
cal e
ntity
con
duct
ing
the
elec
tion
not l
ater
than
the
11th
day
bef
ore
elec
tion
day.
If th
e 11
th d
ay is
a w
eeke
nd o
r hol
iday
,
cale
ndar
yea
r, be
ginn
ing
Janu
ary
1. P
leas
e re
mem
ber t
hat t
he a
pplic
atio
n m
ust b
e re
ceiv
ed n
ot
If yo
u su
bmit
an A
nnua
l App
licat
ion
for B
allo
t by
Mai
l with
in 6
0 da
ys b
efor
e an
ele
ctio
n th
at ta
kes
plac
e in
the
follo
win
g ca
lend
ar y
ear,
your
app
licat
ion
will
be v
alid
for a
ny e
lect
ion
that
take
s pl
ace
in th
e fo
llow
ing
cale
ndar
yea
r, re
gard
less
of t
he fa
ct th
at y
our a
pplic
atio
n w
as s
ubm
itted
prio
r to
the
end
of th
e pr
eced
ing
cale
ndar
yea
r. Th
is a
pplie
s to
Ann
ual A
pplic
atio
ns o
nly
and
not t
o a
regu
lar a
pplic
atio
n fo
r bal
lot b
y m
ail.
Witn
ess/
Ass
ista
nt S
ectio
nW
itnes
s: If
you
are
una
ble
to s
ign
your
nam
e (d
ue to
a p
hysi
cal d
isab
ility
or il
liter
acy)
, the
appl
icat
ion
in B
ox #
10 o
r, if
you
are
unab
le to
mak
e a
mar
k, th
en th
e W
itnes
s m
ust c
heck
the
appr
opria
te b
ox in
11
indi
catin
g th
e in
abilit
y to
mak
e a
mar
k. T
he W
itnes
s m
ust s
tate
his
/her
na
me
in p
rinte
d fo
rm a
nd in
dica
te h
is/h
er r
elat
ions
hip
to y
ou o
r, if
unre
late
d, s
tate
that
fact
. Th
e W
itnes
s m
ust s
ign
and
prov
ide
his
or h
er p
rinte
d na
me
and
resi
denc
e ad
dres
s. U
nles
s th
e W
itnes
s is
a c
lose
rela
tive
of th
e vo
ter (
pare
nt, g
rand
pare
nt, s
pous
e, c
hild
or s
iblin
g), i
t is
a C
lass
B
mis
dem
eano
r for
a p
erso
n to
witn
ess
mor
e th
an o
ne a
pplic
atio
n fo
r bal
lot b
y m
ail.
Assi
stan
t: If
a pe
rson
(ot
her
than
a c
lose
rel
ativ
e or
per
son
regi
ster
ed to
vot
e at
the
sam
e ad
dres
s) a
ssis
ts y
ou in
com
plet
ing
this
app
licat
ion
in y
our p
rese
nce
or m
ails
/faxe
s/e-
mai
ls th
is
appl
icat
ion
on y
our b
ehal
f, th
en th
at p
erso
n m
ust c
ompl
ete
Box
#11.
The
Ass
ista
nt m
ust s
ign,
pr
ovid
e hi
s or
her
prin
ted
nam
e, a
nd h
is o
r her
resi
denc
e ad
dres
s. A
per
son
com
mits
a C
lass
A
mis
dem
eano
r if t
he p
erso
n pr
ovid
es a
ssis
tanc
e w
ithou
t pro
vidi
ng th
e in
form
atio
n de
scrib
ed
abov
e un
less
a c
lose
rela
tive
or re
gist
ered
at y
our a
ddre
ss.
If yo
u ha
ve fu
rthe
r que
stio
ns o
r nee
d ad
ditio
nal a
ssis
tanc
e, p
leas
e co
ntac
t
or w
ww
.sos
.sta
te.tx
.us.
JENISE MILLERELECTIONS ADMINISTRATORHOOD COUNTY1410 West Pearl St.Granbury, TX 76048
