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Alabama Application for Absentee Ballot

The use of the following application is intended for people who are voting pursuant to the Uniformed And Overseas Citizens Absentee Voting Act. This form is used for determining whether a person is eligible to vote or not.

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Primary Election or Presidential Preference PrimarySelect one:	
APPLICATION FOR ABSENTEE BALLOT
______________________  COUNTY, ALABAMA
I hereby make application for an absentee ballot so that I may vote in t\
he following election:
I am applying for an absentee ballot because (check one box):	
I will be out of the county or the state on election day.
I have a physical illness or infirmity which prevents my attendance at the polls.
I have a physical illness or infirmity which prevents my attendance at the polls. I am unable to access my assigned 
polling place due to a neurological, musculoskeletal, respiratory (including speech organs), cardiovascular, or other 
life-altering disorder that affects my ability to perform manual tasks, stand for any length of time, walk unassisted, 
see, hear or speak 	and	:	
a)  I am an elderly voter aged 65 or older; 	or	
b)  I am a voter with a disability.	
I work a shift which has at least ten (10) hours that coincide with the polling hours at my regular polling place.
I am enrolled as a student at an educational institution located outside\
 the county of my personal residence,
attendance at which prevents my attendance at the polls.
I am a member of, or a spouse or dependent of a member of, the Armed Forces of the United States or am other	-	
wise similarly qualified to vote absentee pursuant to the Uniformed and Overseas Citizens  Absentee Voting Act,42 
U.S.C. 1973ff.	
This application for an absentee ballot will be valid for all county, state, and federal elections held during this 
calendar year unless you specify an earlier expiration date here:  _____\
__________________________.  	
I have been appointed as an election officer at a polling place which is not my regular polling place.	
When I apply for this absentee ballot, I understand that my name will be stricken from the list of qualified electors and, 
when I cast this absentee ballot, I understand that I will not be entitled to vote at my regular polling place.
The voter may hand this application to the Absentee Election Manager. The voter may also forward this application to the Absentee Election 
Manager by U.S. Mail [§17-11-3 and §17-11-4, Code of Alabama, 1975]. 	Do not include more than one application per envelope if mailing.  	
READ PENALTIES ON BACK	
Democratic Party	
Voter’s Signature	Witness Signature
Print Witness Name	
Complete this 
section if voter 
signs by mark		
Mail my ballot to the address where I regularly receive mail, if dif ferent from the street address provided above
Precinct where you vote (name and/or location of your polling place)	
Work Telephone Number	
Date of Birth
Home Telephone Number
General Voter Information - 	Please provide complete information so that we may verify your eligibili\
ty to vote.	
Republican Party
Other ____________
Amendments Only	
General Election 	Special Election (	specify	) __________________________	
For all registered voters
n  Absentee ballots for elections more than 42 days apart must be requested\
 on separate applications, unless you are a member 	
of the armed forces, 	or a spouse or dependent of such person,	 or you are a United States citizen residing overseas.	
n  	An application submitted by a member of the armed forces, 	or a spouse or dependent of such person,	 or a United States 	
citizen residing overseas, is valid for all county, state and federal elections in the current calendar year.	
Street Address (address where you are registered to vote; do not use PO box)	City	ZIP	
Year	Day	Month	
(              )	(              )
Last Name (Please print)	First Name	Middle or Maiden Name	
Driver’s License Number	
Return this 
application 
to:
S TAT E	NUMBER	
IF NO DRIVER’S LICENSE NUMBER
Last 4 digits of Social Security number	
E-mail Address	
FORM AV-R1	
State	
Primary Runoff ElectionSelect one:	Democratic Party
Republican Party
Other ____________
Amendments Only	
Democratic Party	Republican Party	If a primary or runoff, check one:	
Revised 2016.08.02

PENALTIES	
§17-17-24, Code of Alabama, 1975, as amended	
	 (a)		Any	person	who	willfully	changes	an	absentee	voter’s	ballot	to	the	extent	that	it	does	not	reflect	the	
voter’s true ballot, any person who willfully votes more than once by absentee\
 ballot in the same election, any 
person	who	willfully	votes	for	another	voter	or	falsifies	absentee	ballot	applications	or	verification	documents	
so as to vote absentee, or any person who solicits, encourages, urges, or otherwise promotes illegal absentee 
voting, shall be guilty, upon conviction, of a Class C felony. Any person who willfully aids any person 
unlawfully to vote an absentee ballot, any person who knowingly and unla\
wfully votes an absentee ballot, and 
any voter who votes both an absentee and a regular ballot at any electio\
n shall be similarly punished.
 (b)  Upon request by the local district attorney or the Secretary of S\
tate, the Attorney General shall 
provide investigating assistance in instances of absentee ballot or voti\
ng violations.
 (c)  Nothing in this section shall be construed to impede or inhibit o\
rganized legal efforts to encourage 
voter participation in the election process or to discourage a candidate\
 from encouraging electors to lawfully 
vote by absentee ballot.
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