State of Missouri | |||
County (City) of _______________ | |||
I, ______ (print name), a registered voter of ______ County (City of St. Louis, Kansas City), declare under the penalties of perjury that I am voting in person at a location designated by the local election authority or I expect to be prevented from going to the polls on election day due to (check one): | |||
______ | absence on election day from the jurisdiction of the election authority in which I am registered; | ||
______ | incapacity or confinement due to illness or physical disability on election day, including caring for a person who is incapacitated or confined due to illness or disability and resides at the same address; | ||
______ | religious belief or practice; | ||
______ | employment as an election authority, by an election authority at a location other than my polling place, as a first responder, as a health care worker, or as a member of law enforcement; | ||
______ | incarceration, although I have retained all the necessary qualifications for voting; | ||
______ | certified participation in the address confidentiality program established under sections 589.660 to 589.681 because of safety concerns. | ||
I hereby state under penalties of perjury that I am qualified to vote at this election; I have not voted and will not vote other than by this ballot at this election. I further state that I marked the enclosed ballot in secret or that I am blind, unable to read or write English, or physically incapable of marking the ballot, and the person of my choosing indicated below marked the ballot at my direction; all of the information on this statement is, to the best of my knowledge and belief, true. | |||
__________________ | __________________ | ||
Signature of Voter | Signature of Person | ||
Assisting Voter | |||
(if applicable) | |||
Signed ______ | Subscribed and sworn | ||
Signed ______ | to before me this | ||
Address of Voter | ______day of ______, ______ | ||
__________________ | __________________ | ||
__________________ | __________________ | ||
Mailing Addresses | Signature of notary or | ||
(if different) | other officer | ||
authorized to | |||
administer oaths |
State of Missouri | ||
County (City) of ______ | ||
I, ______ (print name), declare under the penalties of perjury that I am a citizen of the United States and eighteen years of age or older. I am not adjudged incapacitated by any court of law, and if I have been convicted of a felony or of a misdemeanor connected with the right of suffrage, I have had the voting disabilities resulting from such conviction removed pursuant to law. I hereby state under penalties of perjury that I am qualified to vote at this election. | ||
I am an interstate former resident of Missouri and authorized to vote for presidential and vice presidential electors. | ||
I further state under penalties of perjury that I have not voted and will not vote other than by this ballot at this election; I marked the enclosed ballot in secret or am blind, unable to read or write English, or physically incapable of marking the ballot, and the person of my choosing indicated below marked the ballot at my direction; all of the information on this statement is, to the best of my knowledge and belief, true. | ||
__________________ | Subscribed to and | |
Signature of Voter | sworn before me this | |
______ day of | ||
______, ______ | ||
__________________ | ||
__________________ | __________________ | |
Address of Voter | Signature of notary or | |
other officer | ||
authorized to | ||
administer oaths | ||
__________________ | __________________ | |
Mailing Address (if different) | __________________ | |
__________________ | ||
__________________ | __________________ | |
Signature of Person | Address of Last | |
Assisting Voter | Missouri Residence | |
(if applicable) |
State of Missouri | |||
County (City) of ______ | |||
I, ______ (print name), declare under the penalties of perjury that I expect to be prevented from going to the polls on election day due to (check one): | |||
______ | absence on election day from the jurisdiction of the election authority in which I am directed to vote; | ||
______ | incapacity or confinement due to illness or physical disability on election day, including caring for a person who is incapacitated or confined due to illness or disability and resides at the same address; | ||
______ | religious belief or practice; | ||
______ | employment as an election authority, by an election authority at a location other than my polling place, as a first responder, as a health care worker, or as a member of law enforcement; | ||
______ | incarceration, although I have retained all the necessary qualifications of voting; | ||
______ | certified participation in the address confidentiality program established under sections 589.660 to 589.681 because of safety concerns. | ||
I hereby state under penalties of perjury that I own property in the ______ district and am qualified to vote at this election; I have not voted and will not vote other than by this ballot at this election. I further state that I marked the enclosed ballot in secret or that I am blind, unable to read and write English, or physically incapable of marking the ballot, and the person of my choosing indicated below marked the ballot at my direction; all of the information on this statement is, to the best of my knowledge and belief, true. | |||
__________________ | Subscribed and sworn | ||
Signature of Voter | to before me this | ||
______ day of | |||
______, ______ | |||
__________________ | |||
__________________ | __________________ | ||
Address | Signature of notary or | ||
other officer | |||
authorized to | |||
administer oaths | |||
__________________ | |||
Signature of Person | |||
Assisting Voter | |||
(if applicable) |
The voter needed assistance in marking the ballot and signing above, because of blindness, other physical disability, or inability to read or to read English. I marked the ballot enclosed in this envelope at the voter's direction, when I was alone with the voter, and I had no other communication with the voter as to how he or she was to vote. The voter swore or affirmed the voter affidavit above and I then signed the voter's name and completed the other voter information above. Signed under the penalties of perjury. |
Reason why voter needed assistance: ______ |
ASSISTING PERSON SIGN HERE |
1. ______ (signature of assisting person) |
2. ______ (assisting person's name printed) |
3. ______ (assisting person's residence) |
4. ______ (assisting person's home city or town). |
§ 115.283, RSMo