Feb 11, 2013 - I declare that I am a resident and registered voter of St. Louis County, Missouri, and am permanently dis
ST. LOUIS COUNTY BOARD OF ELECTION COMMISSIONERS APPLICATION FOR PLACEMENT ON PERMANENTLY DISABLED LIST OR CAREGIVER TO PERMANENTLY DISABLED
CHECK ONE: __PERMANENTLY DISABLED OR __CAREGIVER Name:
Birthdate:
Address:
Last 4 digits of SSN: City:
Zip Code:
Phone number: __________________________________ I declare that I am a resident and registered voter of St. Louis County, Missouri, and am permanently disabled or caregiver to a disabled person. I hereby request that my name be placed on the election authority's list of voters qualified to participate as an absentee voter pursuant to Sec. 115.284, and that an absentee ballot application be delivered to me for each election in which I am eligible to vote.
Voter's Signature (or Mark)
Witness to Voter's Mark
Address to which the application for an absentee ballot is to be mailed, if different from voting address: Address: City:
State:
Zip:
NOTE: If an applicant is blind, unable to read or write the English language or is physically incapable of signing the application, he/she shall sign by mark, witnessed by the signature of an election official or a person of his/her own choosing.
RETURN TO: Board of Election Commissioners, 725 Northwest Plaza Drive St. Ann, MO 63074 FAX NUMBER: 314-615-1998 For additional Absentee Voting Information, please call 314-615-1933 or 314-615-1836.
