DO NOT REMOVE PERFORATED TABS. Moisten here and fold bottom to top to seal. DO NOT REMOVE PERFORATED TABS. Moisten here and fold bottom to top to seal.

Application for Ballot by Mail Prescribed by the Office of the Secretary of State of Texas A5-15 12/17

For Official Use OnlyVUID #, County Election Precinct #, Statement of Residence, etc.

1 Last Name (Please print information) Suffix (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:* Used in case our office has questions.

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

Confinement in jail. (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 ONLY Voters Absent from County or Voters Confined in Jail: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.

Mailing Address as listed on my voter registration certificate

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.

11 See back for Witness and Assistant definitions. If 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 a la oficina del Secretario de Estado o la Secretaria de Votación por Adelantado.

_________________________________________________________ ___________________________________

AFFIX LABEL HERE OR ADDRESSTO: EARLY VOTING CLERK

DO NOT REMOVE PERFORATED TABS. Moisten tab and fold top to bottom to seal.

AFFIX FIRST CLASS

POSTAGEFROM: _________________________________

_________________________________

_________________________________

Inst

ruct

ions

for A

pplic

atio

n fo

r Bal

lot b

y M

ail

Res

iden

ce A

ddre

ss -

Giv

e fu

ll ad

dres

s as

sho

wn

on y

our v

oter

regi

stra

tion

certi

ficat

e. If

you

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

Bal

lot t

o a

Diff

eren

t Add

ress

- Yo

ur b

allo

t mus

t be

mai

led

to y

our h

ome

whe

re y

ou liv

e or

to y

our m

ailin

g ad

dres

s on

you

r vot

er re

gist

ratio

n ce

rtific

ate.

The

re a

re s

ome

exce

ptio

ns th

at

allo

w y

ou to

hav

e yo

ur b

allo

t mai

led

to a

diff

eren

t loc

atio

n as

spe

cifie

d be

low.

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 c

hose

exp

ecte

d ab

senc

e fro

m c

ount

y, y

ou 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.

Ann

ual 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

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

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,

your

app

licat

ion

may

be

forw

arde

d to

oth

er e

ntiti

es h

oldi

ng e

lect

ions

whe

re y

ou a

re a

qua

lified

vo

ter.

This

mea

ns th

at y

ou m

ay re

ceiv

e a

ballo

t for

thos

e el

ectio

ns in

add

ition

to th

e ba

llot(s

) yo

u re

ques

ted

with

this

app

licat

ion.

Subm

ittin

g A

pplic

atio

n1.

Sig

n an

d da

te y

our a

pplic

atio

n - I

f una

ble

to s

ign,

ple

ase

go to

Witn

ess/

Addr

ess

boxe

s (1

1 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 C

lerk

- Yo

u m

ay s

ubm

it yo

ur a

pplic

atio

n vi

a th

ese

met

hods

:

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:

You

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

fide,

for p

rofit

car

rier.

By F

ax: Y

ou m

ay fa

x yo

ur a

pplic

atio

n to

the

Early

Vot

ing

Cle

rk. P

leas

e co

ntac

t you

r Ear

ly V

otin

g C

lerk

or t

he S

ecre

tary

of S

tate

’s O

ffice

for f

ax n

umbe

rs.

By E

-Mai

l: Yo

u m

ay e

-mai

l a s

igne

d, s

cann

ed im

age

of y

our a

pplic

atio

n to

the

Early

Vot

ing

Cle

rk.

Plea

se c

onta

ct y

our E

arly

Vot

ing

Cle

rk o

r the

Sec

reta

ry o

f Sta

te’s

Offi

ce fo

r e-m

ail a

ddre

sses

.IF

YO

U F

AX

OR

E-M

AIL

YO

UR

APP

LIC

ATIO

N T

O T

HE

EAR

LY V

OTI

NG

CLE

RK

, YO

U M

UST

A

LSO

MA

IL T

HE

APP

LIC

ATI

ON

SO

TH

AT

THE

CLE

RK

REC

EIVE

S IT

NO

LA

TER

TH

AN

TH

E FO

UR

TH B

USI

NES

S D

AY

AFT

ER T

HE

DA

Y TH

E C

LER

K R

ECEI

VED

YO

UR

FA

XED

OR

EM

AIL

ED A

PPLI

CA

TIO

N.

If

you

fax

or e

-mai

l yo

ur a

pplic

atio

n by

the

de

adlin

e no

ted

belo

w, y

our a

pplic

atio

n w

ill b

e co

nsid

ered

com

plet

e an

d tim

ely

as lo

ng a

s th

e or

igin

al is

rece

ived

by

the

early

vot

ing

cler

k by

the

four

th b

usin

ess

day

afte

r it

was

su

bmitt

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

, th

e de

adlin

e is

the

first

pre

cedi

ng b

usin

ess

day.

You

may

sub

mit

an a

pplic

atio

n th

roug

hout

the

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

late

r tha

n th

e 11

th d

ay b

efor

e th

e fir

st e

lect

ion

in w

hich

you

see

k to

vot

e by

mai

l.

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 t

o a

phys

ical

dis

abilit

y or

illit

erac

y),

the

appl

icat

ion

may

be

sign

ed a

t Box

#11

for

you

by a

Witn

ess.

You

mus

t affi

x yo

ur m

ark

to th

e ap

plic

atio

n in

Box

#10

or,

if yo

u ar

e un

able

to m

ake

a m

ark,

then

the

Witn

ess

mus

t che

ck th

e ap

prop

riate

box

in 1

1 in

dica

ting

the

inab

ility

to m

ake

a m

ark.

The

Witn

ess

mus

t sta

te h

is/h

er

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.

Ass

ista

nt:

If a

pers

on (

othe

r th

an a

clo

se r

elat

ive

or p

erso

n re

gist

ered

to v

ote

at th

e sa

me

addr

ess)

ass

ists

you

in c

ompl

etin

g th

is a

pplic

atio

n in

you

r pre

senc

e or

mai

ls/fa

xes/

e-m

ails

this

ap

plic

atio

n on

you

r beh

alf,

then

that

per

son

mus

t com

plet

e Bo

x #1

1. T

he A

ssis

tant

mus

t sig

n,

prov

ide

his

or h

er p

rinte

d na

me,

and

his

or h

er re

side

nce

addr

ess.

A p

erso

n co

mm

its a

Cla

ss

A m

isde

mea

nor i

f the

per

son

prov

ides

ass

ista

nce

with

out p

rovi

ding

the

info

rmat

ion

desc

ribed

ab

ove

unle

ss a

clo

se re

lativ

e or

regi

ster

ed a

t you

r add

ress

.

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 yo

ur E

arly

Vot

ing

Cle

rk o

r The

Sec

reta

ry o

f Sta

te’s

offi

ce a

t 1-8

00-2

52-8

683

or w

ww

.sos

.sta

te.tx

.us.