AFFIX LABEL HERE OR ADDRESSTO: EARLY VOTING CLERK

AFFIX FIRST CLASS

POSTAGEFROM: _________________________________

_________________________________

_________________________________

Inst

ruct

ions

for A

pplic

atio

n fo

r Bal

lot b

y M

ail

Resi

denc

e Ad

dres

s ha

ve m

oved

with

in th

e co

unty

but

not

yet

cha

nged

you

r vot

er re

gist

ratio

n ad

dres

s w

ith th

e vo

ter

regi

stra

r, in

dica

te y

our n

ew re

side

nce

addr

ess.

Mai

l Bal

lot T

o - G

ive

full a

ddre

ss w

here

you

wis

h to

hav

e ba

llot m

aile

d, if

the

addr

ess

is d

iffer

ent

from

you

r res

iden

ce a

ddre

ss.

Mai

ling

Ballo

t to

a Di

ffere

nt A

ddre

ss -

Your

bal

lot m

ust b

e m

aile

d to

you

r hom

e w

here

you

live

Rea

son

for v

otin

g by

mai

l Lo

catio

n to

mai

l bal

lot

65 o

r dis

able

d N

ursi

ng h

ome,

ass

iste

d liv

ing/

retir

emen

t cen

ter,

rela

tive,

ho

spita

l In

jail

Add

ress

of j

ail o

r rel

ativ

e A

bsen

t fro

m c

ount

y A

ddre

ss lo

cate

d ou

tsid

e of

cou

nty

Expe

cted

Abs

ence

from

Cou

nty

- If y

ou ch

ose

expe

cted

abs

ence

from

coun

ty, yo

u m

ust e

xpec

t to

be

abse

nt fr

om th

e co

unty

on

elec

tion

day

and

durin

g th

e ho

urs

of e

arly

vot

ing

in p

erso

n or

fo

r the

rem

aind

er o

f the

ear

ly v

otin

g pe

riod

afte

r you

sub

mit

your

app

licat

ion.

You

r bal

lot m

ust

be m

aile

d to

an

addr

ess

outs

ide

the

coun

ty. I

mpo

rtant

: Giv

e da

te y

ou c

an b

egin

to re

ceiv

e m

ail a

t the

add

ress

giv

en.

Annu

al A

pplic

atio

n - I

f you

are

65

year

s of

age

or o

lder

, or d

isab

led

you

may

app

ly to

rece

ive

all

will

be c

onsi

dere

d an

Ann

ual A

pplic

atio

n. If

you

sub

mit

an a

nnua

l app

licat

ion

for a

bal

lot b

y m

ail,

vote

r. Th

is m

eans

that

you

may

rece

ive

a ba

llot f

or th

ose

elec

tions

in a

dditi

on to

the

ballo

t(s)

you

requ

este

d w

ith th

is a

pplic

atio

n.

Subm

ittin

g A

pplic

atio

n1.

Sig

n an

d da

te y

our a

pplic

atio

n -

on

reve

rse)

and

hav

e a

pers

on w

itnes

s yo

ur m

ark.

Witn

ess/

Assi

stan

t ins

truct

ions

follo

w b

elow

.

2. D

eliv

er to

Ear

ly V

otin

g Cl

erk

- You

may

sub

mit

your

app

licat

ion

via

thes

e m

etho

ds:

In P

erso

n: O

nly

the

appl

ican

t may

sub

mit

thei

r app

licat

ion

in p

erso

n to

the

Early

Vot

ing

Cle

rk

until

the

early

vot

ing

perio

d be

gins

. How

ever

, afte

r the

ear

ly v

otin

g pe

riod

begi

ns fo

r an

elec

tion,

th

e ap

plic

ant m

ay o

nly

subm

it th

eir a

pplic

atio

n vi

a m

ail,

com

mon

con

tract

car

rier,

fax,

or e

-mai

l.

By M

ail:

Y ou

may

mai

l you

r app

licat

ion

via

the

U.S

. Pos

tal S

ervi

ce.

By C

omm

on C

ontra

ct C

arrie

r: Yo

u m

ay s

ubm

it vi

a a

com

mon

or c

ontra

ct c

arrie

r whi

ch is

a b

ona

By F

ax:

front

of t

his

appl

icat

ion

in B

ox #

9.

By E

-Mai

l:

IF Y

OU

FAX

OR

E-M

AIL

YOUR

APP

LICA

TIO

N TO

THE

EAR

LY V

OTI

NG C

LERK

, YO

U M

UST

ALSO

MAI

L TH

E AP

PLIC

ATIO

N SO

THA

T TH

E CL

ERK

RECE

IVES

IT N

O L

ATER

THA

N TH

E FO

URTH

BUS

INES

S DA

Y AF

TER

THE

DAY

THE

CLER

K RE

CEiV

ED Y

OUR

FAX

ED O

R EM

AILE

D AP

PLIC

ATIO

N. If

you

fax

or e

-mai

l you

r app

licat

ion

by th

e de

adlin

e no

ted

belo

w,

your

app

licat

ion

will

be

cons

ider

ed c

ompl

ete

and

timel

y as

long

as

the

orig

inal

is re

ceiv

ed

by th

e ea

rly v

otin

g cl

erk

by th

e fo

urth

bus

ines

s da

y af

ter i

t was

sub

mitt

ed b

y fa

x or

e-m

ail.

Dea

dlin

eYo

ur a

pplic

atio

n m

ust b

e re

ceiv

ed b

y th

e ea

rly v

otin

g cl

erk

of th

e lo

cal e

ntity

con

duct

ing

the

elec

tion

not l

ater

than

the

11th

day

bef

ore

elec

tion

day.

If th

e 11

th d

ay is

a w

eeke

nd o

r hol

iday

,

cale

ndar

yea

r, be

ginn

ing

Janu

ary

1. P

leas

e re

mem

ber t

hat t

he a

pplic

atio

n m

ust b

e re

ceiv

ed n

ot

If yo

u su

bmit

an A

nnua

l App

licat

ion

for B

allo

t by

Mai

l with

in 6

0 da

ys b

efor

e an

ele

ctio

n th

at ta

kes

plac

e in

the

follo

win

g ca

lend

ar y

ear,

your

app

licat

ion

will

be v

alid

for a

ny e

lect

ion

that

take

s pl

ace

in th

e fo

llow

ing

cale

ndar

yea

r, re

gard

less

of t

he fa

ct th

at y

our a

pplic

atio

n w

as s

ubm

itted

prio

r to

the

end

of th

e pr

eced

ing

cale

ndar

yea

r. Th

is a

pplie

s to

Ann

ual A

pplic

atio

ns o

nly

and

not t

o a

regu

lar a

pplic

atio

n fo

r bal

lot b

y m

ail.

Witn

ess/

Ass

ista

nt S

ectio

nW

itnes

s: If

you

are

una

ble

to s

ign

your

nam

e (d

ue to

a p

hysi

cal d

isab

ility

or il

liter

acy)

, the

appl

icat

ion

in B

ox #

10 o

r, if

you

are

unab

le to

mak

e a

mar

k, th

en th

e W

itnes

s m

ust c

heck

the

nam

e in

prin

ted

form

and

indi

cate

his

/her

rel

atio

nshi

p to

you

or,

if un

rela

ted,

sta

te th

at fa

ct.

The

Witn

ess

mus

t sig

n an

d pr

ovid

e hi

s or

her

prin

ted

nam

e an

d re

side

nce

addr

ess.

Unl

ess

the

Witn

ess

is a

clo

se re

lativ

e of

the

vote

r (pa

rent

, gra

ndpa

rent

, spo

use,

chi

ld o

r sib

ling)

, it i

s a

Cla

ss

B m

isde

mea

nor f

or a

per

son

to w

itnes

s m

ore

than

one

app

licat

ion

for b

allo

t by

mai

l.

Assi

stan

t: If

a pe

rson

(ot

her

than

a c

lose

rel

ativ

e or

per

son

regi

ster

ed to

vot

e at

the

sam

e ad

dres

s) a

ssis

ts y

ou in

com

plet

ing

this

app

licat

ion

in y

our p

rese

nce

or m

ails

/faxe

s/e-

mai

ls th

is

appl

icat

ion

on y

our b

ehal

f, th

en th

at p

erso

n m

ust c

ompl

ete

Box

#11.

The

Ass

ista

nt m

ust s

ign,

pr

ovid

e hi

s or

her

prin

ted

nam

e, a

nd h

is o

r her

resi

denc

e ad

dres

s. A

per

son

com

mits

a C

lass

A

mis

dem

eano

r if t

he p

erso

n pr

ovid

es a

ssis

tanc

e w

ithou

t pro

vidi

ng th

e in

form

atio

n de

scrib

ed

abov

e un

less

a c

lose

rela

tive

or re

gist

ered

at y

our a

ddre

ss.

If yo

u ha

ve fu

rthe

r que

stio

ns o

r nee

d ad

ditio

nal a

ssis

tanc

e, p

leas

e co

ntac

t

or w

ww

.sos

.sta

te.tx

.us.

Suzie HarveyElections AdministratorP.O. Box 2646Conroe, TX 77305-2646

You

may

fax

your

app

licat

ion

to th

e Ea

rly V

otin

g C

lerk

’s fa

x nu

mbe

r as

show

n on

the

You

may

e-m

ail a

sig

ned,

sca

nned

imag

e of

you

r app

licat

ion

to th

e Ea

rly V

otin

g Cl

erk’s

e-m

ail a

ddre

ss a

s sh

own

on th

e fro

nt o

f thi

s ap

plica

tion

in B

ox #

9

ballo

ts b

y m

ail f

or a

cal

enda

r yea

r. If

you

do n

ot s

elec

t any

ele

ctio

ns in

Box

#6a

, you

r app

licat

ion

If un

able

to s

ign,

ple

ase

go to

Witn

ess/

Addr

ess

boxe

s (#

11

appr

opria

te b

ox in

#11

indi

catin

g th

e in

abilit

y to

mak

e a

mar

k. T

he W

itnes

s m

ust s

tate

his

/her

Application for Ballot by Mail 71/21 51-5A VUID #, County Election Precinct #, Statement of Residence, etc.

1 Last Name (Please print information) (Jr., Sr., III, etc) First Name Middle Initial

2 Residence Address: See back of this application for instructions. City ,TX ZIP Code

3 Mail my ballot to: If mailing address differs from residence address, please complete Box # 7. City State ZIP Code

4 Date of Birth (mm/dd/yyyy) (Optional) Contact Information (Optional)*Please list phone number and/or email address:*

5 Reason for Voting by Mail:65 years of age or older. (Complete Box #6a)

Disability. (Complete Box #6a)

Expected absence from the county. (Complete Box #6b and Box #8)You will receive a ballot for the upcoming election only

(Complete Box #6b) You will receive a ballot for the upcoming election only

6a ONLY Voters 65 Years of Age or Older or Voters with a Disability:If applying for one election, select appropriate box. If applying once for elections in the calendar year, select “Annual Application.”

Annual Application

Uniform and Other Elections:

May Election

November Election

Other ___

Primary Elections:You must declare one political party to vote in a primary:

Democratic Primary

Republican Primary

Any Resulting Runoff

6b You may only apply for a ballot by mail for one election, and any resulting runoff.Please select the appropriate box.

Uniform and Other Elections:

May Election

November Election

Other ___________________

Primary Elections:You must declare one political party to vote in a primary:

Democratic Primary

Republican Primary

Any Resulting Runoff

7 If you are requesting this ballot be mailed to a different address (other than residence), indicate where the ballot will be mailed. See reverse for instructions.

Nursing home, assisted living facility, or long term care facility

Hospital

Retirement Center

Address of the jail

Relative; relationship _______________

Address outside the county (see Box #8)

8 If you selected “expected absence from the county,” see reverse for instructions

Date you can begin to receive mail at this address Date of return to residence address

9 Voters may submit a completed, signed, and scanned application to the Early Voting Clerk at:

(early voting clerk’s e-mail address ) (early voting clerk’s fax)

NOTE: If you fax or e-mail this form, please be aware that you must also mail the form to the early voting clerk within four business days. See “Submitting Application” on the back of this form for additional information.

10 “I certify that the information given in this application is true, and I understand that giving false information in this application is a crime.”

X Date

SIGN HEREIf applicant is unable to sign or make a mark in the presence of a witness, the witness shall complete Box #11.

If someone helped you to complete this form or mails the form for you, then that person must complete the sections below.

11If applicant is unable to mark Box #10 and you are acting as a Witness to that fact, please check this box and sign below.

If you assisted the applicant in completing this application in the applicant’s presence or e-mailed/mailed or faxed the application on behalf of the applicant, please check this box as an Assistant and sign below.

*If you are acting as Witness and Assistant, please check both boxes. Failure to complete this information is a Class A misdemeanor if signature was witnessed or applicant was assisted in completing the application.

XSignature of Witness /Assistant

XPrinted Name of Witness/Assistant

Street Address Apt Number (if applicable) City

State ZIP Code

Witness’ Relationship to Applicant(Refer to Instructions on back for clarification)

Este formulario está disponible en Español. Para conseguir la version en Español favor de llamar sin cargo al 1.800.252.8683

_________________________________________________________ ___________________________________election.ballot@mctx.org (936) 788-8340