Please complete the form below to request Vote By Mail (absentee) Ballots. If you have any
questions about this form, please e-mail us at abrequests@votenassau.com
| Voter Information: |
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Voter's First Name: |
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Voter's Middle Name: |
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Voter's Last Name: |
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Voter's Birth Date (mm/dd/yyyy): |
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Nassau County Residence Address (No PO Box): |
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Voter's Apt, Lot, or Unit Number: |
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Voter's City: |
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Voter's ZIP Code: |
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| * One of the following two items must be provided. |
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Voter's E-mail Address: |
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Voter's Facsimile Number: |
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Voter's Daytime Phone: |
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Voter ID Number (if available): |
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Mailing Address |
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| Check if this is your permanent mailing address |
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| If making this request for someone other than yourself, F.S. 101.62 requires you to provide the following information about yourself: |
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Requester's Name: |
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Requester's Address: |
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Requester's Driver's License Number (if available): |
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Requester's Relationship to Voter: |
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| You may only request Vote By Mail (absentee) Ballots for yourself and your immediate family, which is defined as your spouse, child, parent, grandparent, sibling, spouse's child, parent, grandparent, sibling, or legal guardian. |
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Absentee Status:
Military/Dependent Overseas
Civilian Overseas
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| Vote By Mail (Absentee) Ballots Requested: |
| A special request for a facsimile or electronic absentee ballot must be made for each specific election. |
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Check method you would like ballots transmitted to you: (select only one)
By mail
By e-mail
By facsimile - Valid for 1 election, a request must be submitted for each election. |
| If your mailing address, facsimile, phone number or e-mail address changes, be sure and notify our office immediately. |
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