Request to Cancel Permanent Absentee or Mail-In Status

Form Purpose and Instructions

This document is a form from the Pennsylvania Department of State used by voters to cancel their permanent absentee or mail-in ballot status. It is designed for individuals who currently receive an annual application for these ballots but wish to stop receiving them.

Instructions:

• Step 1: Fill out the form.
• Step 2: Sign and date the form.
• Step 3: Mail or deliver the completed form to your county voter registration office.

Required Information

To process the request, the voter must provide the following details:

• Printed Name: Last name, first name, middle initial, and suffix (Jr. , Sr. , II, III, IV).
• Identification: Either a PA driver's license/PennDOT ID number OR the last four digits of the Social Security number.
• Date of Birth: Month, day, and year.
• Address: The street address (not a P. O. Box) where the voter is registered to vote in Pennsylvania, including city/town, municipality, county, state, and zip code.
• Contact Information: Phone number and email address (both are optional).

Legal Notice

The form includes a notice stating that false statements on the form are punishable pursuant to 18 Pa. C. S. § 4904 (relating to unsworn falsification to authorities).

Submission

The form must be signed and dated by the voter before submission. The completed form should be sent to the appropriate county election office.

County Election Office Addresses

Page 2 of the document provides a comprehensive list of addresses and contact information for County Election Offices across Pennsylvania. This includes offices for counties such as Adams, Allegheny, Philadelphia, and York, among others. The list provides street addresses, P. O. boxes, cities, zip codes, and phone numbers for each county office.

A note at the bottom of page 2 indicates that a listing of available email addresses can be found at www. votesPA. com/county.