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Pennsylvania Application for Emergency Absentee Ballot

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Document Overview

This is an official form from the Pennsylvania Department of State for residents to apply for an Emergency Absentee Ballot. The form is designed for voters who are unable to vote in person on election day due to specific emergencies or circumstances.

Key Information

  • Jurisdiction: Pennsylvania (Department of State)
  • Form Date: 05/2020 (Visible in the bottom right corner)
  • Purpose: To request a ballot for an emergency situation where the voter cannot reach their polling place.

Instructions and Requirements

The form is divided into seven numbered sections requiring specific information:

  1. Name: Print your name exactly as registered (Last, First, Middle, Suffix).
  2. About You: Provide your birth date (MM/DD/YYYY) and occupation.
  3. Your Address: List your current residential address (not a P. O. Box), including city, municipality, county, and zip code. You must also state how long you have lived at this address and whether you are a State or Federal Government employee.
  4. Ballot Mailing: Indicate if you want the ballot mailed to a different address (e. g. , P. O. Box or temporary residence).
  5. Identification: You must provide either your PA driver's license/PennDOT ID number or the last four digits of your Social Security number.
  6. Reason for Application: You must check one of the following reasons to justify an emergency application:
    • Illness or physical disability preventing application prior to the deadline.
    • Becoming physically ill or disabled after the deadline.
    • Expecting to be absent from your municipality on election day (and did not know this prior to the deadline).
    • Circumstances preventing you from appearing at the polling place on election day.
  7. Help with this form: This section is for voters who are unable to sign their own name due to illness or physical disability. It requires a witness's signature and the voter's mark (X) in lieu of a signature.

Important Notes

  • Ink: Use black ink only.
  • Legal Warning: The form states that providing false information is subject to penalties under 18 Pa. C. S. § 4904 (unsworn falsification).
  • Election Day Rule: If you receive an absentee ballot but return your voted ballot by the deadline, you may vote a provisional ballot at your polling place on election day.
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