Free 47090.pdf - Indiana

State Form 47090 (R8 / 10-07) Indiana Election Commission (IC 3-11-4-2; 3-11-4-5.1; 3-11-10-24)

APPLICATION FOR ABSENTEE BALLOT BY MAIL ONLY

For Election on ______/_______/________

Reset Form

(ABS-2)

INSTRUCTIONS: Complete and return this application so that it is received by your county election board at least 8 days before election day. NOTE: Certain voters who registered by mail are required to provide additional personal identification documentation before voting an absentee ballot by mail. Contact your county voter registration office for information if you think this requirement may apply to you. The primary election choice boxes may be deleted for a general election. DEADLINE DATES: For the May 6, 2008 Primary Election, the Deadline for the county to receive this application is MONDAY, APRIL 28, 2008 BY MIDNIGHT. For the November 4, 2008 General Election, the Deadline for the county to receive this application is MONDAY, OCTOBER 27, 2008 BY MIDNIGHT. (THIS FORM CAN BE MAILED, FAXED, OR HAND-DELIVERED.)

To the county election board:
Name (please print)
1. INFORMATION OF ABSENTEE BALLOT APPLICANT Date of Birth (mm/dd/yy)

Voter Identification Number (Indiana issued driver's license number, OR if voter does not possess driver's license, provide last 4 digits of social security number) (optional) Telephone Number (Day) ( )

Registration Address (number and street)

______/______/______ City/Town, State, ZIP Code

2. ABSENTEE BALLOT MAILING ADDRESS (Please mail the absentee ballot for the election to me at this address if different from registration address)

Mailing Address (number and street)
If this application is for a PRIMARY ELECTION, check the political party ballot that you are requesting:

City/Town, State, ZIP Code
DEMOCRATIC REPUBLICAN OR Check School Board Only AND/OR Public Question Only

3. REASON TO VOTE ABSENTEE BALLOT BY MAIL I have a specific, reasonable expectation of being absent from the county on election day during the entire 12 hours that the polls are open. I will be confined to my residence, a health care facility, or a hospital due to illness or injury during the entire 12 hours that the polls are open. I will be caring for an individual confined to a private residence due to illness or injury during the entire 12 hours that the polls are open. I am a voter with disabilities. NOTE: If you are unable to mark the ballot or sign the ballot security envelope, you must contact the county election board to process your application. I am a voter at least 65 years of age. I will have official election duties outside of my voting precinct. I am scheduled to work at my regular place of employment during the entire 12 hours that the polls are open. I am unable to vote at the polls in person due to observance of a religious discipline or religious holiday during the entire 12 hours the polls are open. I am a voter eligible to vote under the "fail-safe" procedures in IC 3-10-11 or 3-10-12. I am an address confidentiality program participant in the program administered by the Indiana Attorney General under IC 5-26.5-1-6.

NOTE: If you wish to vote by absentee ballot before a traveling board or in person at the county clerk's office, or if you wish for the person holding a power of attorney to apply for you, contact your county election board.

I swear or affirm under the penalties of perjury that all of the information set forth on this application is true to the best of my knowledge and belief. Perjury is punishable by a term of imprisonment for up to 3 years, a fine of up to $10,000 or both.

Signature of voter (or person designated by election board to sign for a disabled voter)

Date signed (month, day, year) _____________/_____________/_____________
Telephone Number (Day) ( ) Telephone Number (Evening) ( )
City/Town, State, ZIP Code

4. INFORMATION OF INDIVIDUAL ASSISTING ABSENTEE BALLOT APPLICANT

Name (please print)
Registration Address (number and street)

Date Assistance to Applicant Provided
City/Town, State, ZIP Code

_______/_________/_________

Mailing Address (If different from residence address)

I swear or affirm under the penalties of perjury that I have no knowledge or reason to believe that the individual submitting the application: (1) is ineligible to vote or to cast an absentee ballot; or (2) did not properly complete and sign the application.

Signature of Person Assisting Voter with Application
FOR OFFICE USE ONLY

Date signed (month, day, year) _________/___________/___________
Is applicant required to provide additional documentation to the county voter registration office but has not yet done so? Yes No

Date

/

/

Precinct:

Indiana County Offices
Complete and sign this absentee ballot application and mail it to the county where you are registered to vote or to the Indiana Election Division.
ADAMS Adams Co. Circuit Court Clerk P.O. Box 189 Decatur, IN 46733 ­ 0189 (260) 724-5505 ALLEN Allen Co. Circuit Court Clerk 606 South Calhoun St. Fort Wayne, IN 46802 (260) 449-7329 BARTHOLOMEW Bartholomew Co. Circuit Court Clerk P.O. Box 924 Columbus, IN 47202 - 0924 (812) 379-5363 BENTON Benton Co. Circuit Court Clerk th 706 E. 5 Street Suite 37 Fowler, IN 47944 - 1556 (765) 884-0930 BLACKFORD Blackford Co. Circuit Court Clerk 110 W. Washington St. Hartford City, IN 47348 - 2298 (765) 348-1130 BOONE Boone Co. Circuit Court Clerk Room 212, Courthouse Square Lebanon, IN 46052 - 2100 (765) 482-3510 BROWN Brown Co. Circuit Court Clerk P.O. Box 85 Nashville, IN 47448 - 0085 (812) 988-5512 CARROLL Carroll Co. Circuit Court Clerk 101 W. Main St. Delphi, IN 47348 - 1566 (765) 564-4485 CASS Cass Co. Circuit Court Clerk 200 Court Park, Room 103 Logansport, IN 46947 - 3192 (574) 753-7740 CLARK Clark Co. Circuit Court Clerk City-County Bldg., Room 137 501 E. Court Avenue Jeffersonville, IN 47130 - 4090 (812) 285-6329 CLAY Clay Co. Circuit Court Clerk 609 E. National Ave., Rm 213 Brazil, IN 47834 (812) 448-9024 CLINTON Clinton Co. Circuit Court Clerk 265 Courthouse Square Frankfort, IN 46041 - 1993 (765) 659-6335 CRAWFORD Crawford Co. Circuit Court Clerk P.O. Box 375 316 Court St. English, IN 47118 - 0375 (812) 338-2565 DAVIESS Daviess Co. Circuit Court Clerk 200 E. Walnut Street P.O. Box 739 Washington, IN 47501 - 0739 (812) 254-8669 DEARBORN Dearborn Co. Circuit Court Clerk 215 W. High Street Lawrenceburg, IN 47025 - 1909 (812) 537-8867 DECATUR Decatur Co. Circuit Court Clerk 150 Courthouse Square Suite 244 Greensburg, IN 47240 - 2080 (812) 663-8223 DEKALB Dekalb Co. Circuit Court Clerk P.O. Box 230 100 S. Main Street Auburn, IN 46706 - 0230 (260) 927-4725 DELAWARE Delaware Co. Circuit Court Clerk 100 West Main Street Muncie, IN 47305 (765) 747- 7726 DUBOIS Dubois Co. Circuit Court Clerk One Courthouse Square, Room 104 Jasper, IN 47546 - 3058 (812) 481-7037 ELKHART Elkhart Co. Circuit Court Clerk 101 North Main Street, Rm 204 Goshen, IN 46526 (574) 535-6430 FAYETTE Fayette Co. Circuit Court Clerk P.O. Box 607 Connersville, IN 47331 - 0607 (765) 825-1813 FLOYD Floyd Co. Circuit Court Clerk st 311 W. 1 St. Rm. 235 P.O. Box 1056 New Albany, IN 47150 (812) 948-5415 FOUNTAIN Fountain Co. Circuit Court Clerk P.O. Box 183 Covington, IN 47932 (765) 793-2192 FRANKLIN Franklin Co. Circuit Court Clerk 459 Main Street Brookville, IN 47012 - 1486 (765) 647-5111 FULTON Fulton Co. Circuit Court Clerk P.O. Box 524 Rochester, IN 46975 (574) 223-4824 GIBSON Gibson Co. Circuit Court Clerk P.O. Box 630 Princeton, IN 47670 - 0630 (812) 385-2541 GRANT Grant Co. Circuit Court Clerk Courthouse th 101 E. 4 Street Marion, IN 46952 (765) 668-8121 GREENE Greene Co. Circuit Court Clerk P.O. Box 229 Bloomfield, IN 47424 - 0229 (812) 384-8532 HAMILTON Hamilton Co. Circuit Court Clerk 1 Hamilton County Square Suite 106 Noblesville, IN 46060 - 2230 (317) 776-8476 HANCOCK Hancock Co. Circuit Court Clerk 9 East Main Street Room 201 Greenfield, IN 46140 (317) 477-1109 HARRISON Harrison Co. Circuit Court Clerk Courthouse, Room 203 300 North Capitol Avenue Corydon, IN 47112 - 1155 (812) 738-4289 HENDRICKS Hendricks Co. Circuit Court Clerk P.O. Box 599 Danville, IN 46122 - 0599 (317) 745-9231 HENRY Henry Co. Circuit Court Clerk P.O. Box B New Castle, IN 47362 - 1044 (765) 529-6401 HOWARD Howard Co. Circuit Court Clerk 104 North Buckeye Street, Room 114 P.O. Box 9004 Kokomo, IN 46904 (765) 456-2204 HUNTINGTON Huntington Co. Circuit Court Clerk P.O. Box 228 201 North Jefferson Street, Rm 201 Huntington, IN 46750 (260) 358-4819 JACKSON Jackson Co. Circuit Court Clerk 111 South Main Street P.O. Box 122 Brownstown, IN 47220 - 0122 (812) 358-6117 JASPER Jasper Co. Circuit Court Clerk 115 West Washington St., Suite 204 Rensselaer, IN 47978 (219) 866-4927 JAY Jay Co. Circuit Court Clerk 120 Court Street Portland, IN 47371 ­ 2195 (260) 726-6915 JEFFERSON Jefferson Co. Circuit Court Clerk Courthouse, Room 203 300 East Main Street Madison, IN 47250 - 3594 (812) 265-8926 JENNINGS Jennings Co. Circuit Court Clerk P.O. Box 385 Vernon, IN 47282 - 0385 (812) 352-3070 JOHNSON Johnson Co. Circuit Court Clerk P.O. Box 368 Franklin, IN 46131 - 0451 (317) 736-3708 KNOX Knox Co. Circuit Court Clerk th 101 North 7 Street Vincennes, IN 47591 - 2022 (812) 885-2521 KOSCIUSKO Kosciusko Co. Circuit Court Clerk 121 North Lake Street Warsaw, IN 46580 - 2788 (574) 372-2334 LAGRANGE LaGrange Co. Circuit Court Clerk 105 North Detroit Street LaGrange, IN 46761 - 1801 (260) 499-6371 LAKE Lake Co. Board of Voter Registration 2293 North Main Street, Suite 16 Crown Point, IN 46307 (219) 755-3795 LAPORTE LaPorte Co. Circuit Court Clerk 813 Lincolnway, Suite 105 LaPorte, IN 46350 - 3492 (219) 326-6808 ext. 465 LAWRENCE Lawrence Co. Circuit Court Clerk th 916 15 St. Room 31 Bedford, IN 47421 - 3800 (812) 275-4145 MADISON Madison Co. Circuit Court Clerk th 16 East 9 Street, Suite 213 Anderson, IN 46016 (765) 641-9457 MARION Marion Co. Circuit Court Clerk 200 East Washington, W122 Indianapolis, IN 46204 (317) 327-5100 MARSHALL Marshall Co. Circuit Court Clerk 211 West Madison Street Plymouth, IN 46563 - 1762 (574) 935-8701 MARTIN Martin Co. Circuit Court Clerk 111 Main St. P.O. Box 120 Shoals, IN 47581 (812) 247-3651 MIAMI Miami Co. Circuit Court Clerk P.O. Box 184 Peru, IN 46970 - 0184 (765) 472-3901 ext. 256 MONROE Monroe Co. Circuit Court Clerk P.O. Box 547 Bloomington, IN 47402 (812) 349-2600 MONTGOMERY Montgomery Co. Circuit Court Clerk P.O. Box 768 Crawfordsville, IN 47933 - 0768 (765) 364-6434 MORGAN Morgan Co. Circuit Court Clerk P.O. Box 1556 Martinsville, IN 46151 - 1556 (765) 342-1026 NEWTON Newton Co. Circuit Court Clerk P.O. Box 49 Kentland, IN 47951 - 0049 (219) 474-6081 NOBLE Noble Co. Circuit Court Clerk 101 North Orange Street Albion, IN 46701 ­ 1092 (260) 636-2736 OHIO Ohio Co. Circuit Court Clerk P.O. Box 185 Rising Sun, IN 47040 - 0185 (812) 438-2610 ORANGE Orange Co. Circuit Court Clerk 1 Court Street Orange County Courthouse Paoli, IN 47454 - 9632 (812) 723-2649 OWEN Owen Co. Circuit Court Clerk P.O. Box 146 Spencer, IN 47460 - 0146 (812) 829-5015 PARKE Parke Co. Circuit Court Clerk 116 West High Street Room 204 Rockville, IN 47872 - 1781 (765) 569-5132 PERRY Perry Co. Circuit Court Clerk 2219 Payne Street Tell City, IN 47586 - 2832 (812) 547-3741 PIKE Pike Co. Circuit Court Clerk P.O. Box 125 Petersburg, IN 47567 (812) 354-6025 PORTER Porter Co. Circuit Court Clerk 16 E. Lincolnway, Rm 209 Valparaiso, IN 46383 (219) 465-3450 POSEY Posey Co. Circuit Court Clerk P.O. Box 606 Mt. Vernon, IN 47620 - 0606 (812) 838-1306 PULASKI Pulaski Co. Circuit Court Clerk 112 East Main Room 230 Winamac, IN 46966 - 1394 (574) 946-6038 PUTNAM Putnam Co. Circuit Court Clerk P.O. Box 546 Greencastle, IN 46135 - 0546 (765) 653-2648 RANDOLPH Randolph Co. Circuit Court Clerk P.O. Box 230 Winchester, IN 47394 - 0230 (765) 584-4214 RIPLEY Ripley Co. Circuit Court Clerk P.O. Box 177 115 N. Main Street Versailles, IN 47042 (812) 689-6115 RUSH Rush Co. Circuit Court Clerk 101 East 1st Street P.O. Box 429 Rushville, IN 46173 - 0429 (765) 932-2086 ST. JOSEPH St. Joseph Co. Circuit Court Clerk 101 South Main Street South Bend, IN 46614 (574) 235-9635 SCOTT Scott Co. Circuit Court Clerk 1 East McClain Avenue, Suite 120 Scottsburg, IN 47170 - 1885 (812) 752-8420 SHELBY Shelby Co. Circuit Court Clerk 407 S. Harrison St., Ste 111 Shelbyville, IN 46176 (317) 392-6320 SPENCER Spencer Co. Circuit Court Clerk P.O. Box 12 200 Main Street Rockport, IN 47635 - 0012 (812) 649-6029 STARKE Starke Co. Circuit Court Clerk P.O. Box 395 Knox, IN 46534 (574) 772-9128 STEUBEN Steuben Co. Circuit Court Clerk 55 South Public Square Angola, IN 46703 ­ 1945 (260) 668-1000 ext. 2220 SULLIVAN Sullivan Co. Circuit Court Clerk P.O. Box 370 Sullivan, IN 47882 - 0370 (812) 268-4657 SWITZERLAND Switzerland Co. Circuit Court Clerk Courthouse 212 West Main Vevay, IN 47043 - 1180 (812) 427-3175 TIPPECANOE Tippecanoe Board of Elections P.O. Box 619 Lafayette, IN 47901 (765) 423-9220 TIPTON Tipton Co. Circuit Court Clerk 101 East Jefferson Tipton, IN 46072 - 1901 (765) 675-2795 UNION Union Co. Circuit Court Clerk 26 West Union Street Liberty, IN 47353 - 1396 (765) 458-6121 VANDERBURGH Vanderburgh Co. Circuit Court Clerk P.O. Box 3356 Evansville, IN 47732 - 3356 (812) 435-5160 VERMILLION Vermillion Co. Circuit Court Clerk P.O. Box 10 Newport, IN 47966 - 0008 (765) 492-3500 VIGO Vigo Co. Circuit Court Clerk P.O. Box 8449 Terre Haute, IN 47808 (812) 462-3235 WABASH Wabash Co. Circuit Court Clerk 69 West Hill Street Wabash, IN 46992 (260) 563-0661 ext. 230 WARREN Warren Co. Circuit Court Clerk 125 North Monroe Street Suite 11 Williamsport, IN 47993 - 1198 (765) 762-3510 WARRICK Warrick Co. Circuit Court Clerk 1 County Square Suite 200 Boonville, IN 47601 - 1594 (812) 897-6163 WASHINGTON Washington Co. Circuit Court Clerk 99 Public Square, Ste 102 Salem, IN 47167 (812) 883-5748 WAYNE Wayne Co. Circuit Court Clerk 301 E. Main Street Richmond, IN 47374 (765) 973-9224 WELLS Wells Co. Circuit Court Clerk 102 West Market Street Suite 201 Bluffton, IN 46714 - 2091 (260) 824-6482 WHITE White Co. Circuit Court Clerk P.O. Box 350 Monticello, IN 47960 - 0350 (574) 583-1530 WHITLEY Whitley Co. Circuit Court Clerk 101 West Van Buren Street Columbia City, IN 46725 - 2087 (260) 248-3102 INDIANA ELECTION DIVISION 302 West Washington St., RM E204 Indianapolis, IN 46204 (800) 622-4941