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 Freddy Burton, Saline County Clerk

215 N. Main, Suite 9, Benton, AR  72015

        Phone:  (501) 303-5630    Fax:  (501)  776-2412

APPLICATION FOR ABSENTEE BALLOT

IF YOU PROVIDE FALSE INFORMATION ON THIS FORM, YOU MAY BE GUILTY OF PERJURY AND SUBJECT TO A FINE OF UP To $10,000 OR IMPRISONMENT FOR UP TO 10 YEARS.

I REQUEST AN ABSENTEE BALLOT BECAUSE (CHECK ONE):

(  )  I Will be unavoidable absent from my polling site on election day, or

(  )  I Will be unable to attend the polls on election day because of illness or physical disability, or residence in a long-term or residential facility license by the state.

I RESIDE (CHECK ONE):

(  )  within the county in which I am registered to vote (application valid for one election & runoff)

(  )  outside the county in which I am registered to vote (application valid for one election & runoff)

(  )  I am a member of the uniformed services of the United States in active service

(  )  outside territorial limits of U.S. or District of Columbia (application valid for 2 federal general elections)

I REQUEST THE APPROPRIATE ABSENTEE BALLOT(S) FOR THE FOLLOWING ELECTIONS:
(  ) Presidential Preferential Primary Election (indicate Political Party Preference)___________________
(  ) Nonpartisan Judicial General Election only
(  ) Democratic Preferential Primary / Nonpartisan Judicial General and Runoff

(  ) Republican Preferential Primary/Nonpartisan Judicial

General and Runoff
(  ) General Election and Runoff (  ) Annual School Election and Runoff
(  ) Special Election on ___________________ (Date) and Runoff, in applicable.
(  ) All Elections for current calendar year.  I am disabled, in a long-term care facility, or living outside the county.  (DESIGNATE PARTY)  (  ) Democrat  (  )  Republican
(  )  All Elections through the next 2 Federal General Election cycles. I am a uniformed services personnel, a U.S. citizen residing outside the U.S. territorial limits and DC, a merchant marine, or the spouse or dependent of these voters.

I WILL RECEIVE MY BALLOT BY (CHECK ONE):

(  )  coming to the office of the county clerk by the time the county clerk's office regularly closes on the day before the election

(  )  Mail.  I request that you mail my ballot to the following address:

_______________________________________

_______________________________________

_______________________________________

 

(  )  Designated Bearer, Administrator, or authorized Agent.

___________________________________________________

(INSERT NAME)

(NOTE:  A designated bearer can only pick up 2 absentee ballots and can only do so within the 15 days before a general election or the 7 days before a general primary election.  Anyone may distribute blank absentee ballot applications.)

The information I have provided is true to the best of my knowledge under penalty of perjury.  If I have provided false information, I may be subject to a fine of up to ten thousand dollars ($10,000) or imprisonment for up to ten (10) years, or both, under federal laws.

 

Print Voter name____________________________ Voter Signature____________________________

 

Street Address_______________________________  Date of Birth____________________________

 

City, State & Zip _____________________________   _____________________________________

                                                                                         Signature of Bearer, or  Authorized Agent

 

              

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