Absentee Ballot Request - Flagler County (for residents of Flagler County)

Ballots Requested:
All Elections
City / District / Special Elections, if eligible
Primary Election
General Election
Presidential Preference Primary

First Name:

Middle Name:

Last Name:

Date of Birth: (mm/dd/yyyy)
mm01020304 05060708 09101112 / dd0102 03040506 07080910 11121314 15161718 19202122 23242526 27282930 31 / yyyy19891988198719861985 1984198319821981 1980197919781977 1976197519741973 1972197119701969 1968196719661965 1964196319621961 1960195919581957 1956195519541953 1952195119501949 1948194719461945 1944194319421941 1940193919381937 1936193519341933 1932193119301929 1928192719261925 1924192319221921 1920191919181917 1916191519141913 1912191119101909 1908190719061905 1904190319021901 1900

Request is:
Permanent               Temporary

Voter Absentee Status:

Civilian Overseas	Military/Dependent Stateside
Disabled	Military/Dependent Overseas
Other (Please Describe)

Street Address:

City:

State:
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist. of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip:

Is this an address change? 
Yes No -

Mailing Address:

City:

State:
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist. of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip:

Area Code and Telephone Number:
- -

E-Mail Address: (optional)

Request by immediate family member or legal guardian - In addition to the above required  information, Florida law requires all of the following information if an immediate family member or legal guardian has been directed (designated) by the voter to request an absentee ballot.

Requestor's Complete Name:		Relationship to Elector:
Requestor's Street Address:		Requestor's City:
Requestor's State:		Requestor's Zip:
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist. of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Disclosure

DATE:        SIGNATURE:
 (If emailing your request, please type your name above.)
Your request for an absentee ballot can be made in person, by postal mail, electronic mail (e-mail) or telephone. To make your request by telephone,  please call (386) 313-4170. If sending by postal mail or hand delivery, please print and sign this form.