Application For Absent Voter's Ballots

Date __________________

I the undersigned, say that my voting residence in Nebraska is;

_________________________________________________________NE______________

(Street or Route NO) PO Box # (If Applicable) City State ZipCode

my election precinct ___________________, Dakota County, State of Nebraska and I am a

registered Voter of the State of Nebraska.

I request ballots be mailed to __________________________________________________

Street Address and box # if applicable

________________________________, ____________________, ______________.

(City) (State) (Zip)

I affiliate with the following party; please check one:

___ Democrat, ___Libertarian, ___Republican, ___ Non-Partisan (Independent), _____ Other _________________

(Name of Party)

_____________________________________ _______________________________________

(VOTER PRINT NAME HERE) (VOTER SIGN HERE)

______________________________________________________________________________

(Spouse, Parent, Son or Daughter or Person Appointed as Agent)

=========DO NOT WRITE BELOW THIS LINE - FOR OFFICE USE ONLY ===========

Voter ID Number _____________

School Dist: 011 SSC 31R Homer 561 Emer-Hubb

001 Ponca 070 Allen 004 Jackson

Live within City Limits? Yes No

If Yes- SSC Dakota City Emerson Homer Hubbard Jackson