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Alabama Application for Emergency Absentee Ballot

The following application is used to determine a voter’s eligibility for certain types of elections in the State of Alabama.


Extracted Text for Proper Search

______________________  COUNTY, ALABAMA
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 entitl\
ed to vote at my regular polling place.
The voter, or his or her designee in the case of a medical emergency, may hand this application to the Absentee Election 
Manager. Except in the case of a business emergency, 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].	
Voter’s Signature	Witness Signature
Print Witness Name	
Complete this 
section if voter 
signs by mark		
Street Address (address where you are registered to vote; do not use PO box)
Mail my ballot to the address where I regularly receive mail, if different 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.	
For all registered voters	
Physician shall describe and certify the circumstances as constituting t\
he emergency.	
Physician’s Signature 	Date	
An application for an emergency medical absentee ballot may be forwarded\
 to the Absentee Election Manager by the 
applicant or his or her designee. If assigning a designee, complete this\
Printed Name of Designee	Signature of Designee	
I will be unable to vote at my regular polling place on election day bec\
ause (check one reason):	
I have a medical emergency. Complete the Physician’s Report below. The physician’s report must be signed by a 
physician. [If the physician’s report is on a separate document, attach it to this application. This application may be 
delivered by a designee. If assigning a designee, complete the Designee \
section at the bottom of this form.]
I have a business emergency. By signing this application, I do solemnly swear or affirm that I was not aware of 
the out-of-county business requirement prior to the five (5) days before the election. [The voter must deliver the 
application by hand to the Absentee Election Manager during the five (5) days prior to the election.]	
City	ZIP	
Year	Day	Month	
(              )	(              )
Last Name (Please print)	First Name	Middle or Maiden Name	
Driver’s License Number
Last 4 digits of Social Security number	
E-mail Address	
Return this application to:	
Primary Election or Presidential Preference Primary
Select one:	
I hereby make application for an absentee ballot so that I may vote in t\
he following election:	
Democratic Party
Republican Party
Other ____________
Amendments Only	
Primary Runoff Election 
Select one:	Democratic Party
Republican Party
Other ____________
Amendments Only	
General Election 	Special Election (	specify	) ________________________	
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.	
For Office Use Only	
Municipal Election

§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 b\
allot 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 unlawfully votes a\
n absentee ballot, and any voter who 
votes both an absentee and a regular ballot at any election shall be sim\
ilarly punished. 
(b) Upon request by the local district attorney or the Secretary of St\
ate, the Attorney General shall provide 
investigating assistance in instances of absentee ballot or voting viola\
(c) Nothing in this section shall be construed to impede or inhibit or\
ganized 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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