Designated Agent Form

Overview

This document is the Designated Agent Form issued by the Pennsylvania Department of State. It allows voters with disabilities to authorize a specific person (a designated agent) to assist them in picking up or returning mail-in and absentee ballot materials.

Purpose of the Form

Voters can use this form to choose someone to help them vote by mail. The designated agent is authorized to:

• Pick up and return the application for a mail-in or absentee ballot.
• Pick up and return the completed mail-in or absentee ballot.
• Provide other necessary help with voting.

Eligibility

This form is available to any voter who:

• Has a disability.
• Needs assistance picking up or returning their ballot or other voting materials.

Instructions for Use

1. Voter Section: The voter must complete the top half of the form, including their name, address, and the name of their designated agent. They must sign and date the form.
2. Agent Section: The designated agent must complete the bottom half of the form with their personal details and sign it.
3. Copies: It is recommended to make a copy of the completed form (a photo on a phone is acceptable) for your records.
4. Submission: The designated agent must have the completed form with them when picking up or returning the ballot.
5. Important Warning: Do not put this form in the yellow secrecy envelope with your completed ballot.

Restrictions on Agents

You may choose anyone to be your designated agent, with the following exceptions:

• Your employer or an agent of your employer.
• An officer or agent of your union.

The document notes that it is illegal for anybody to intimidate or coerce a voter in exercising their right to vote.

Contact Information

For more information about voting by mail, residents are directed to:

• Website: vote. pa. gov/mailballot
• Phone: 1-877-868-3772
• Local Office: Your county board of elections