Contra Costa Secretary
Resume:
NOTICE
You have the right to mail or deliver this application directly to your county elections official. Returning this application to anyone other than your county elections official may cause a delay that could interfere with your ability to vote. If this application is returned by mail, it must be returned directly to your county elections official. Only the registered voter himself or herself may apply for a vote-by-mail ballot. An application for a vote-by-mail ballot made by a person other than the registered voter is a criminal offense.
INDIVIDUALS/ORGANIZATIONS/GROUPS DISTRIBUTING THIS APPLICATION The format used on this application must be followed by anyone distributing vote-by-mail ballot applications. Failure to conform to this format is a crime. Anyone distributing this application may not preprint a mailing address in Item 5. Anyone providing this application to a voter must enter their name, address, and telephone number here: Warning: Perjury is a felony, punishable by imprisonment in state prison for up to four years. (Penal Code § 126) California Vote-By-Mail Ballot Application
FOR OFFICIAL USE ONLY
REV 03/2018
Enter the date of the election and the type of election (e.g., Primary, General, or Special). This application must be received by your county elections official not later than seven (7) days prior to the date of the election. The date of the election can be found at www.sos.ca.gov/elections/upcoming-elections/. A ballot will not be sent to you if this application is incomplete or inaccurate.
THIS IS AN APPLICATION FOR A VOTE-BY-MAIL BALLOT FOR THE ELECTION. PRINT NAME: 3. DATE OF BIRTH:
RESIDENCE ADDRESS:
MAILING ADDRESS FOR BALLOT (IF DIFFERENT FROM ABOVE): If your mailing address is outside of the U.S., and you are a military or overseas voter, re-register at RegisterToVote.ca.gov or use the Federal Post Card Application at www.fvap.gov. TELEPHONE NUMBER (OPTIONAL):
YES, I WANT TO BECOME A PERMANENT VOTE-BY-MAIL VOTER. By checking this box and by initialing here, I am requesting to become a permanent vote-by-mail voter. A vote-by-mail ballot will automatically be sent to me in all future elections. I understand that if I fail to vote by mail in four consecutive statewide general elections, I will need to reapply for permanent vote-by-mail voter status. THIS APPLICATION MUST BE SIGNED.
I have not applied for a vote-by-mail ballot from any other jurisdiction for this election. I certify under penalty of perjury under the laws of the State of California that the information I have provided on this application is true and correct. 1.
2.
4.
5.
6.
7.
8.
SIGNATURE DATE
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Month/Day/Year Type of Election (Primary, General, or Special) Number and Street (P.O. Box, Rural Route, etc. will not be accepted) (Designate N, S, E, W if used) City Zip Code California County
Number and Street/P.O. Box (Designate N, S, E, W if used) City State or Foreign Country Zip Code or Postal Code Day Evening
First Middle or Initial Last Month/Day/Year
WHO CAN USE THIS APPLICATION
The uniform California Vote-By-Mail Ballot Application can only be used by a registered voter. If you have not already registered to vote, you can register to vote online on the Secretary of State’s website at RegisterToVote.ca.gov. You may also pick up a Voter Registration Card at your county elections office, library, or U.S. Post Office. Your completed Voter Registration Card must be submitted online or to your county elections office at least 15 days before the election.
To vote by mail, you can use this Vote-By-Mail Ballot Application, use the form in the county voter information guide you receive in the mail before an election, or contact your county elections office. County contact information can be found online at www.sos.ca.gov/elections/ voting-resources/ county-elections-offices/.
This Vote-By-Mail Ballot Application is provided by the Secretary of State (SOS) for use by any person, group, or organization distributing vote-by-mail ballot applications for elections that involve more than one county. For organizations distributing applications for elections that involve a single county, the county elections office should be contacted for the appropriate application format and barcode information. Californians who are serving in the military and are absent from the county where they are eligible to vote, and Californians living or studying abroad may register as a military or overseas voter, either online at RegisterToVote.ca.gov or via the Federal Post Card Application (FPCA). Doing so provides more options for receiving your ballot and ensures priority service. The FPCA and other important information for military and overseas voters is available at www.fvap.gov.
How to Fill Out this Application
ITEM 1. Enter the date of the election in which you wish to vote (month, day, year), and the type of election
(Primary, General, or Special).
ITEM 2. Print your first, middle, and last names as they appear on your Voter Registration Card.
ITEM 3. Print your date of birth in this order – month, day, year.
ITEM 4. Print the complete street address of your
voting residence. A post office box or rural route cannot be accepted.
ITEM 5. Mailing address information must be
completed by the voter. Print the complete address where you want your ballot sent if it is different than the residence address provided in Item 4.
ITEM 6. Print your telephone number (optional, not required) to allow the elections office to contact you if more information is needed.
ITEM 7. Any registered voter may receive a vote-by-mail ballot automatically in all future elections by checking the Permanent Vote-By-Mail Voter box and initialing the line. Any voter can opt out of the permanent vote- by-mail status at any time by contacting their county elections official directly.
ITEM 8. Sign and date in this order – month, day, year. No witness or notary required.
HOW TO SUBMIT THE APPLICATION
Your Vote-By-Mail Ballot Application must be returned to your county elections official at least 7 days before the election. However, if you become ill or disabled during the final week before an election, or find that you will be unable to go to your polling place on Election Day, you may request that a vote-by-mail ballot be delivered to you by submitting a written statement, signed under penalty of perjury to your county elections official. The statement must contain your name and residence address, the address to which you want the ballot sent, the name and date of the election in which you would like to vote, your signature, and the date. You may authorize another person to receive the ballot from the elections official, and/or return the ballot to an elections official after you have voted it.
If this application is returned by mail, it must be returned directly to your county elections official.
Please do not send applications to the SOS’s office. Doing so will delay the application process.
You can find the address and telephone number of your county elections official on the SOS website at www.sos.ca.gov/ elections/voting-resources/county-elections-offices/. WHAT CAN BE PREPRINTED ON THE APPLICATION
State law requires the voter to personally affix his or her signature and the address to which the ballot is to be mailed. If an organization is distributing the application, the name, address, and telephone number of the organization authorizing distribution must be included on the application.
In order to ensure accuracy, each voter should fill out all of the information on the application. However, any person, group, or organization distributing the application may preprint the following:
• The printed name and home address of the voter as it appears on the Voter Registration Card.
• The name and date of the election for which the ballot is requested.
• The name, address, and telephone number of the person, group, or organization authorizing distribution of the application.
(Revised March 2018)
ALAMEDA
1225 Fallon Street, Room G-1
Oakland, CA 94612
ALPINE
P.O. Box 158
Markleeville, CA 96120
AMADOR
810 Court Street
Jackson, CA 95642
BUTTE
155 Nelson Ave
Oroville, CA 95965-3411
CALAVERAS
891 Mountain Ranch Road
San Andreas, CA 95249
COLUSA
546 Jay Street, Suite 200
Colusa, CA 95932
CONTRA COSTA
P.O. Box 271
Martinez, CA 94553
DEL NORTE
981 H Street, Room 160
Crescent City, CA 95531
EL DORADO
P.O. Box 678001
Placerville, CA 95667
FRESNO
2221 Kern Street
Fresno, CA 93721
GLENN
516 W. Sycamore Street
Willows, CA 95988
HUMBOLDT
2426 6th Street
Eureka, CA 95501
IMPERIAL
940 W. Main Street, Suite 206
El Centro, CA 92243
INYO
P.O. Drawer F
Independence, CA 93526
KERN
1115 Truxtun Avenue
Bakersfield, CA 93301
KINGS
1400 W. Lacey Blvd.
Hanford, CA 93230
LAKE
255 N. Forbes Street
Lakeport, CA 95453
LASSEN
220 S. Lassen Street, Suite 5
Susanville, CA 96130
LOS ANGELES
P.O. Box 1024
Norwalk, CA 90651-1024
MADERA
200 W. 4th Street
Madera, CA 93637
MARIN
P.O. Box E
San Rafael, CA 94913-3904
MARIPOSA
P.O. Box 247
Mariposa, CA 95338
MENDOCINO
501 Low Gap Road, Rm 1020
Ukiah, CA 95482
MERCED
2222 M Street, Room 14
Merced, CA 95340
MODOC
108 E. Modoc Street
Alturas, CA 96101
MONO
P.O. Box 237
Bridgeport, CA 93517
MONTEREY
P.O. Box 4400
Salinas, CA 93912
NAPA
1127 1st Street, Ste. E
Napa, CA 94559
NEVADA
950 Maidu Avenue, Suite 250
Nevada City, CA 95959
ORANGE
P.O. Box 11298
Santa Ana, CA 92711
PLACER
P.O. Box 5278
Auburn, CA 95604
PLUMAS
520 Main Street, Room 102
Quincy, CA 95971
RIVERSIDE
2724 Gateway Drive
Riverside, CA 92507-0918
SACRAMENTO
7000 65th Street, Suite A
Sacramento, CA 95823-2315
SAN BENITO
440 Fifth Street, Room 206
Hollister, CA 95023-3843
SAN BERNARDINO
777 E. Rialto Avenue
San Bernardino, CA 92415-0770
SAN DIEGO
P.O. Box 85656
San Diego, CA 92186-5656
SAN FRANCISCO
1 Dr. Carlton B. Goodlett Place,
Room 48
San Francisco, CA 94102-4635
SAN JOAQUIN
P.O. Box 810
Stockton, CA 95201
SAN LUIS OBISPO
1055 Monterey Street,
Room D-120
San Luis Obispo, CA 93408
SAN MATEO
40 Tower Road
San Mateo, CA 94402
SANTA BARBARA
P.O. Box 61510
Santa Barbara, CA 93160-1510
SANTA CLARA
P.O. Box 611360
San Jose, CA 95161-1360
SANTA CRUZ
701 Ocean St., Room 310
Santa Cruz, CA 95060
95060-4076
SHASTA
P.O. Box 990880
Redding, CA 96099-0880
SIERRA
P.O. Drawer D
Downieville, CA 95936-0398
SISKIYOU
510 N. Main Street
Yreka, CA 96097-9910
SOLANO
675 Texas Street,
Suite 2600
Fairfield, CA 94533
SONOMA
P.O. Box 11485
Santa Rosa, CA 95406-1485
STANISLAUS
1021 I Street, Suite 101
Modesto, CA 95354-2331
SUTTER
1435 Veterans Memorial Circle
Yuba City, CA 95993
TEHAMA
P.O. Box 250
Red Bluff, CA 96080-0250
TRINITY
P.O. Box 1215
Weaverville, CA 96093-1258
TULARE
5951 S. Mooney Blvd.
Visalia, CA 93277
TUOLUMNE
2 S. Green Street
Sonora, CA 95370-4696
VENTURA
800 S. Victoria Avenue,
L-1200
Ventura, CA 93009-1200
YOLO
P.O. Box 1820
Woodland, CA 95776-1820
YUBA
915 8th Street, Suite 107
Marysville, CA 95901-5273
California Secretary of State (800) 345-VOTE (8683) www.sos.ca.gov https://voterstatus.ca.gov CALIFORNIA COUNTY ELECTIONS OFFICES
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