Emergency Absentee Ballot: Authorize a Representative Form

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 authorized to pick up and return the ballot if it has been completed by the voter and sealed in the required envelopes.
• Contact Information: For more information, voters can visit VotesPA. com/mailballot or call 1-877-868-3772.

Form Sections and Instructions

The document is divided into four numbered sections requiring specific information:

1. Voter’s Name and Address

   • Requires 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.
   • By signing, the voter agrees that the representative is only allowed to handle the sealed ballot addressed to the County Board of Elections.

3. Representative’s Name and Address

   • Requires 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.
   • By signing, the representative agrees to only obtain/return the ballot for this specific voter and to do so only after the voter has completed and sealed it.