Application for Ballot by Mail

Texas Driver’s License, Texas Personal Idencaon Number

or Elecon Idencaon Cercate Number issued by the

Department of Public Safety (NOT your voter registraon VUID#)

___ ___ ___ ___ ___ ___ ___ ___

If you do not have a Texas Driver’s License, Texas Personal

Idencaon Number or a Texas Elecon Idencaon Cercate

Number, give the last 4 digits of your Social Security Number

X X X - X X -

___ ___ ___ ___

I have not been issued a Texas Driver’s License/Texas Personal

Idencaon Number/Texas Elecon Idencaon Cercate or

Social Security Number

Applicaon for a Ballot by Mail

If someone helps you complete this form or mails, emails or faxes this form for you, that person must complete the Witness/Assistant Box 6 below. If you email or fax this form to the

Early Vong Clerk, you must also send the original hardcopy to the Early Vong Clerk. If you are faxing or emailing this form on or near the deadline to apply for a Ballot by Mail, you must

send the original hardcopy so that the Clerk receives it no later than the fourth business day aer the day the Clerk received your email or fax. Original signatures are required on both the

fax or email image and the physical hard copy. Electronic signatures are not permitted. THE HARDCOPY OF THIS APPLICATION MUST BE RECEIVED BY THE EARLY VOTING CLERK AND

MEET ALL LEGALLY REQUIRED DEADLINES. Please read the instructions on the back of this form completely. If you have any questions, please call the Tarrant County Elections office

at 817-831-8683, Texas Secretary of State at at 1-800-252-8683, or email votebymail@tarrantcountytx.gov.

1. Voter Informaon: Please print all informaon clearly and legibly YOU MUST PROVIDE ONE of the following numbers

Name: _____________________________________________________________________________________________________

Last, First, Middle Sux (Jr., Sr.)

Address: ___________________________________________________________________________________________________

Street Apt. # (if any) City State Zip Code

Oponal Informaon: Providing this informaon is helpful to the Early Vong Clerk to clarify any informaon on this applicaon and/or

your voted mail ballot.

Residence Address as shown on your Voter Registraon Cercate

Date of Birth: _______ /_______ /_________ VUID #: ____________________________________ Pct #: ____________________

Email: ____________________________________________________________ Tel. #: ___________________________________

2. Mail my Ballot to:

My Residence Address (as listed on my Voter Registraon Cercate)

Other Address - You may use the Other Address line only if the other address ts one of the categories below.

_________________________________________________________________________________________________________________________________________________________________

Address Apt. # (if any) City State Zip Code

My Other Address is: (Check one)

The mailing address listed on my Voter Registraon Cercate

Address Outside the County (voters absent from the county)

Hospital, Nursing Home, Long-Term Care Facility, Rerement or Assisted Living Center or a Relave _______________________________________________________________ (Indicate Relaonship)

Address of the Jail/Civil Commitment Facility or a Relave

_______________________________________________________________________________________________ (Indicate Relaonship)

Annual Applicaon

Send me a ballot for all Elecons in this vong year (January – December) Annual Applicaons

only available for voters 65 and older and voters with disabilies. You must select a party if you

wish to vote in a primary. Select only one party’s primary and its resulng runo.

(Voters who are absent from the county or conned in jail/civilly commied may only apply for

one elecon and its resulng runo.)

Uniform Elecon Dates

November Elecon May Elecon (not a primary runo)

Any Resulng Runo Other Special Elecon: __________________________________

(Name or Date of Special Elecon, if known)

Primary Elecon (even numbered years only)

Democrac Primary Any Resulng Runo

Republican Primary Any Resulng Runo

Democrac Primary Any Resulng Runo

Republican Primary Any Resulng Runo

Do Not Send me a Primary Ballot

Primary Elecon (even numbered years only)

3. Reason For Vong by Mail:

65 Years of Age or Older

Disability (as dened in Texas Elecon Code 82.002(a), see instrucons on reverse) By checking this box, I arm that, “I have a sickness or physical condion that prevents me from appearing at the polling

place on elecon day without a likelihood of needing personal assistance or injuring my health.”

Expected to give birth within three weeks before or aer Elecon Day

Expected Absence from the County (You may apply for a ballot for one elecon and its resulng runo, if your dates of absence from the county include both elecons)

Date you can begin to receive mail at your out of county address: ____________ /____________ /_____________ Date of return to residence address: ____________ /____________ /_____________

Conned in Jail or Involuntary Civil Commitment (You may only apply for a ballot for one elecon and any resulng runo)

4. Send me a Ballot for the Following Elecons:

5. Sign Here:

“I cerfy that the informaon given in this applicaon is true, and I understand that giving false informaon in this applicaon is a crime.”

on given in this applicaon is true,

X________________________________________________________________ Date:

____________ /____________ /_____________

If applicant is unable to sign or make a mark (in the presence of a witness), the witness must complete the witness poron in Box 6 below. The signature or mark of the voter in the blank above must be an original

signature made with a pen and ink. Electronic signatures are not permied.

6. If someone helps you complete this form or mails, emails or faxes the form for you, that person must complete the secon below.

Instrucons for Witnesses and Assistants: See back of this form for the denions of Witness and Assistant.

Check one or both boxes below if you served as a Witness, an Assistant or both. All informaon below must be completed!

If the applicant is unable to make a mark, you must check this box and complete all informaon below. Do not sign for the voter in Box 5.

Witness – If you are acng as a Witness to the applicant’s signature or mark or signing on the applicant’s behalf, you must state your relaonship to the applicant here: ______________________________

(Indicate Relaonship)

Assistant – If you assisted the applicant in compleng this applicaon in the applicant’s presence or mailed/emailed/faxed the applicaon on behalf of the applicant.

Failure to complete this secon is a Class A Misdemeanor if applicant’s signature was witnessed or applicant was assisted in compleng this applicaon.

X______________________________________ ___________________________________________

Signature of Witness/Assistant Printed Name of Witness/Assistant

____________________________________________________________________________________________________________________________

Street Address Apt. # (if any) City State Zip Code

Este formulario está disponible en Español. Para conseguir la versión en Español favor llamar la officina de Elecciones del Condado de Tarrant al 817-831-8683 o www.tarrantcountytx.gov.

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____________________________________OM: FR

____________________________________

T SY FIRAPPL

CLASS MAIL

GE HEREATPOS

EARLY VOTING CLERK

TARRANT COUNTY ELECTIONS ADMINISTRATION

PO BOX 961011

FORT WORTH TX 76161-0011