Minn. R. agency 133, ch. 8210, ABSENTEE BALLOT MATERIALS; INSTRUCTIONS, pt. 8210.0800
On the back of the absentee signature envelope provided for in Minnesota Statutes, section 203B.21, a certificate of eligibility must be printed on the envelope in the form shown in subpart 3a. The county auditor must provide the Certificate of Eligibility as an electronic document to voters who requested electronic delivery of absentee ballots.
| Signature Envelope | |
| Voter must complete this section | please print clearly |
Voter name _____
Voter MN address (present or last) _____
_____ MN
ID number
(MN driver's license #,
MN ID card #,
U. S. passport #,
or last four digits of SSN)_____
Email _____
Phone (optional) _____
I swear or affirm, under penalty of perjury, that I am (check one):
| () a member of the uniformed services or merchant marine on active duty or an eligible spouse or dependent of such a member; | |
| () a United States citizen temporarily residing outside the United States; | |
| () other United States citizen residing outside the United States; | |
| and | |
| . | I am a United States citizen, |
| . | at least 18 years of age (or will be by the date of the election), and |
| . | I am eligible to vote in the requested jurisdiction; |
| . | I have not been convicted of a felony, or other disqualifying offense, or been adjudicated mentally incompetent, or, if so, my voting rights have been reinstated; and |
| . | I am not registering, requesting a ballot, or voting in any other jurisdiction in the United States except the jurisdiction cited in this voting form. |
| . | In voting, I have marked and sealed my ballot in private and have not allowed any person to observe the marking of the ballot, except for those authorized to assist voters under state or federal law. I have not been influenced. |
The information on this form is true, accurate, and complete to the best of my knowledge. I understand that a material misstatement of fact in completion of this document may constitute grounds for a conviction for perjury.
| Voter SignatureX _____ |
The secretary of state shall provide samples of the layout of the front and the back of the envelope.
Minn. R. agency 133, ch. 8210, ABSENTEE BALLOT MATERIALS; INSTRUCTIONS, pt. 8210.0800
Statutory Authority: MS s 201.061; 201.221; 203B.04; 203B.08; 203B.09; 203B.125; 204B.45