Pennsylvania Application for Emergency Absentee Ballot

Document Overview

This is an official form from the Pennsylvania Department of State for residents to apply for an Emergency Absentee Ballot. It is designed for voters who missed the standard deadline or are unable to vote in person due to specific emergencies.

Key Requirements & Instructions

• Ink: Use black ink only.
• Registration: All information must be printed exactly as it appears on the voter's registration record.
• Deadline Warning: If you receive and return this ballot by the deadline, you cannot vote in person on election day. If you fail to return it by the deadline, you may only vote a provisional ballot unless you surrender the absentee envelope.

Form Sections Breakdown

1. Personal Identification

• Name: Print full name (Last, First, Middle) and suffix (Jr. , Sr. , II, III, IV).
• Demographics: Provide birth date (MM/DD/YYYY) and occupation.

2. Address Information

• Residence: Provide the full address (not a P. O. Box), including city, state, zip code, municipality, county, ward, and voting district.
• Residency Duration: Indicate how long you have lived at this address.
• Government Employee Status: Check "Yes" if you are a State or Federal Government employee.

3. Ballot Mailing Preferences

• Delivery Method: You can choose to have the ballot mailed to your current address or a different address (P. O. Box allowed).
• Recommendation: The form advises considering in-person pickup to avoid mail processing delays.

4. Identification Verification

• Primary ID: Enter your PA driver’s license or PennDOT ID number.
• Secondary ID: If you do not have a PA driver's license or PennDOT ID, you must provide the last four digits of your Social Security number.
• Exemption: There is a checkbox for individuals who possess neither a PA driver's license/PennDOT ID nor a Social Security number.

5. Reason for Application

Applicants must check one of the following qualifying reasons:

• Illness or physical disability prevented applying before the deadline.
• Business, duties, or occupation prevented timely application.
• Physical illness or disability occurred after the deadline to submit a non-emergency application.
• Unexpected absence from the municipality on election day (where the voter did not know they would be absent prior to the deadline).

Declaration: The applicant must sign and date the form, declaring under penalty of law (18 Pa. C. S. § 4904) that the information is true and correct.

6. Assistance (Section 7)

• If the voter is unable to sign due to illness or physical disability, a witness section is provided.
• The voter must mark their signature in the presence of a witness, who must then provide their address and signature.