United States Attorney General

**** ******** ****** ***** ****** Application

**If you are a participant in the Address Confidentiality Program, do not complete this form. Contact the Department of Attorney General.**

I am a United States citizen and a qualified and registered elector of the county and jurisdiction in the state of Michigan listed below, and I am applying for an official ballot, to be voted by me at the election(1 s) listed below.

COMPLETE

Voter’s registration information

Last name First name M.I. County

Street address City

Township

Jurisdiction

City State MI ZIP Year of birth

Email address Phone number

Your email address and phone number will be used only for official election purposes. 2

CHECK

Select election(s) to receive a ballot (required): Presidential Primary May August November

Other elections: Complete to join the permanent absent voter ballot list (optional) Automatically send me an absent voter ballot for each future election for which I’m eligible. 3

SIGN

Voter’s signature (Power of attorney is not acceptable): I certify I am a United States citizen and the statements in this absent voter ballot application are true. Signature Date

WARNING: You must be a United States citizen to vote. If you are not a United States citizen, you will not be issued an absent voter ballot. A person making a false statement in this absent voter ballot application is guilty of a misdemeanor. See reverse side for additional instructions and warnings 4

OTHER

Address to mail ballot:

(Only fill out if different than above)

The U.S. Postal Service will not forward your ballot. We can mail it to you where you are. If additional addresses are needed or plans change, contact your city/township clerk.

Date departing Date of return

Street address

City

State ZIP

Address 1

Date departing Date of return

Street address

City

State ZIP

Address 2

CLERK’S

USE

ONLY

Wd/Pct Mailed / / Returned / /

Filed / / Ballot No. Clerk

See other side for more information and the

Certificate of Authorized Registered Elector Returning Absent Voter Ballot Application Michigan Absent Voter Ballot Application (Rev. 04/24) 1 Michigan Absent Voter Ballot Application (Rev. 04/24) 2 Instructions for absent voter ballot applicants

Step 1: Fill out the application completely. You must sign the form to get a ballot. Step 2: Deliver the application in any of these ways: 1. Instead of returning a paper application, you can apply online at Michigan.gov/Vote. Or you can email a copy of this form. Take a picture of the application (or scan it) and email it to your clerk. Make sure your signature is visible.

2. Mail it. If postage is not prepaid, make sure the envelope has proper postage and is addressed to your local clerk.

3. Deliver it in person to the clerk, the clerk’s office, the clerk’s authorized assistant or the clerk’s drop box. Someone in your immediate family or living in your household can help you deliver this application. If that’s not possible, you can ask any Michigan registered voter to deliver it for you. The person helping you must sign the following “Certificate of Authorized Registered Elector Returning Absent Voter Ballot Application”. Certificate of Authorized Registered Elector Returning Absent Voter Ballot Application

(Complete only if assisting a voter with return of the application) I certify that my name is, date of birth is and

my address is ;

that I am delivering the absent voter ballot application of at his or her request; that I did not solicit or request to return the application; that I have not made any markings on the application; that I have not altered the application in any way; that I have not influenced the applicant; and that I am aware that a false statement in this certificate is a violation of Michigan election law. Signature of person assisting voter Date

Contact your local clerk

Return this application to your city/township clerk. You can find your local clerk’s address, email address, phone number and drop box locations by going to Michigan.gov/Vote or by scanning the QR code below. WARNING: You must be a United States citizen to vote. If you are not a United States citizen, you will not be issued an absent voter ballot. A person making a false statement in this absent voter ballot application is guilty of a misdemeanor. It is a violation of Michigan election law for a person other than those listed in the instructions to return, offer to return, agree to return, or solicit to return your absent voter ballot application to the clerk. An assistant authorized by the clerk who receives absent voter ballot applications at a location other than the clerk’s office must have credentials signed by the clerk. Ask to see his or her credentials before entrusting your application with a person claiming to have the clerk’s authorization to return your application.

Personally identifiable information collected on this form is limited to what’s needed to complete your transaction. As a public body, MDOS is subject to the Michigan Freedom of Information Act (FOIA), MCL 15.231 et seq., and information such as a name or address may be disclosed in response to a FOIA request. For other ways your information may be used, visit https://www.michigan.gov/sos/policies.

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