Authorization to pick up and/or return Emergency Absentee Ballot

Document Overview

This form is issued by the Pennsylvania Department of State to allow a voter to authorize a representative to pick up and/or return their emergency absentee ballot. This is intended for voters who are unable to perform these tasks themselves.

Key Requirements and Deadlines

• Submission Deadline: The form and the ballot must be returned to the County Board of Elections by 8:00 p. m. on election day.
• Ballot Handling: The representative is only allowed to pick up and return the completed ballot if it has been sealed in the required envelopes addressed to the County's Board of Elections.
• Representative Limit: The representative is designated solely for this specific voter and purpose.

Form Sections

The document is divided into four numbered sections requiring information:

1. Voter's Name and Address: Fields for the voter's full name, street address, city/town, county, state, and zip code.
2. Voter's Signature: The voter must sign and date the form to authorize the representative listed below.
3. Representative's Name and Address: Fields for the representative's full name, street address, city/town, county, state, and zip code.
4. Representative's Signature: The representative must sign and date the form to agree to serve as the designated agent.

Contact Information

For more information, the document directs users to:

• Website: vote. pa. gov/mailballot
• Phone: 1-877-868-3772