APPLICATION FOR EMERGENCY ABSENTEE BALLOT FORM AV-E1
______________________ COUNTY, ALABAMA
Return this application to:
General Voter Information - Please provide complete information so that we may verify your eligibility to vote.
Last Name (Please print) First Name Middle or Maiden Name E-mail Address
If you have moved since registering to vote, please update your voter registration record with the county board of registrars before proceeding with this application.
Street Address (address where you are registered to vote; do not use PO box) City ZIP
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) Date of Birth Home Telephone Number ( )
Month Day Year
Driver’s License Number
Work Telephone Number ( )
STATE
NUMBER
IF NO DRIVER’S LICENSE NUMBER Last 4 digits of Social Security number
For all registered voters I hereby make application for an absentee ballot so that I may vote in the following election(s):
Absentee ballots for elections more than 30 days apart must be requested on separate applications. See note below*.
For Military and U.S. Citizens Residing Overseas This section is for individuals voting pursuant to the Uniformed and Overseas Citizens Absentee Voting Act (UOCAVA).
By checking this box, I am attesting that I am a member of the United States Armed Forces or I am a United States citizen residing overseas, or a spouse or dependent of such person. I understand that this application will be valid for an emergency absentee ballot for the current election AND for all elections to be held during the next two regularly scheduled general election cycles for federal offices. If I wish to waive this right and have this application expire earlier, I am providing an expiration date below. For example, I might choose an earlier expiration date if I expect a change of duty station effective after the next election but before the end of the next two general election cycles. This application should expire on
Month / Day / Year
Primary Election or Presidential Preference Primary Election Select one: Democratic Party Republican Party Other Proposed Constitutional Amendments Only Primary Runoff Election Select one: Democratic Party Republican Party Other ____________ Proposed Constitutional Amendments Only General Election Special Election Municipal Election Municipal Runoff Election
*Unless you are a member of the armed forces or you are a United States citizen residing overseas, or a spouse or dependent of such person, please note that for elections to be held more than thirty (30) days apart, you must submit a separate application for absentee voting for each election.
I will be unable to vote at my regular polling place on election day because (check one box): 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.] 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. Voter’s Signature
Complete this section if voter signs by mark
Witness Signature Print Witness Name
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]. READ PENALTIES ON BACK PHYSICIANS REPORT FOR MEDICAL EMERGENCY Physician shall describe and certify the circumstances as constituting the emergency.
Physician’s Signature
Date
ASSIGNMENT OF DESIGNEE FOR DELIVERY OF APPLICATION 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 section.
Printed Name of Designee Signature of Designee
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 unlawfully votes an absentee ballot, and any voter who votes both an absentee and a regular ballot at any election shall be similarly punished. (b) Upon request by the local district attorney or the Secretary of State, the Attorney General shall provide investigating assistance in instances of absentee ballot or voting violations. (c) Nothing in this section shall be construed to impede or inhibit organized legal efforts to encourage voter participation in the election process or to discourage a candidate from encouraging electors to lawfully vote by absentee ballot.
Absentee Election Managers State of Alabama
Revised 10/03/2008
Autauga County Whit Moncrief Absentee Election Manager P. O. Box 681450 Prattville AL 36067 334‐358‐6801 Baldwin County Jane Still Absentee Election Manager 312 Courthouse Square Ste. 27 Bay Minette AL 36507 251‐937‐0261 Barbour County David S. Nix Absentee Election Manager 303 East Broad St. Rm. 201 Eufaula AL 36027 334‐687‐1500 Bibb County Gayle S. Bearden Absentee Election Manager P. O. Box 185 Centreville AL 35042 205‐926‐3103 Blount County Michael E. Criswell Absentee Election Manager 220 Second Ave. E. , Rm. 208 Oneonta AL 35121 205‐625‐4153 Bullock County Wilbert M. Jernigan Absentee Election Manager P. O. Box 230 Union Springs AL 36089 334‐738‐2280 Butler County Allen W. Stephenson Absentee Election Manager P. O. Box 236 Greenville AL 36037 334‐382‐7166 Calhoun County Ted Hooks Absentee Election Manager 25 W. 11th St. Ste. 300 Anniston AL 36201 256‐231‐1750 Chambers County Charles W. Story Absentee Election Manager 2 LaFayette St. S. Ste B114 LaFayette AL 36862 334‐864‐4348 Cherokee County Dwayne Amos Absentee Election Manager 100 Main St. Rm. 203 Centre AL 35960 256‐927‐3637 Chilton County Glenn D. McGriff Absentee Election Manager P. O. Box 1946 Clanton AL 35046 205‐755‐4275 Choctaw County Donna L. Murphy Absentee Election Manager P. O. Box 428 Butler AL 36904 205‐459‐2155 Clarke County Jay Duke Absentee Election Manager P. O. Box 921 Grove Hill AL 36451 251‐275‐3363 Clay County Jeffery L. Colburn Absentee Election Manager P. O. Box 816 Ashland AL 36251 256‐354‐7926 Cleburne County Jerry P. Owen Absentee Election Manager 120 Vickery St. Ste. 202 Heflin AL 36264 256‐463‐2651 Coffee County James M. "Mickey" Counts Absentee Election Manager P. O. Box 311284 Enterprise AL 36331 334‐393‐2750 Colbert County Nancy L. Hearn Absentee Election Manager 201 N. Main St. Tuscumbia AL 35674 256‐314‐5854 Conecuh County David Jackson Absentee Election Manager 111 Court St. Rm. 203 Evergreen AL 36401 251‐578‐7012 Coosa County Jeff Wood Absentee Election Manager P. O. Box 98 Rockford AL 35136 256‐377‐2678 Covington County Roger A. Powell Absentee Election Manager 1‐K North Court Square Andalusia AL 36420 334‐428‐2520 Crenshaw County Sandra Berry Absentee Election Manager P.O. Box 263 Luverne AL 36049 334‐335‐6575
Absentee Election Managers State of Alabama
Revised 10/03/2008
Cullman County Robert G. Bates Absentee Election Manager 500 Second Ave. SW. Ste. 303 Cullman AL 35055 256‐775‐4770 Dale County Mary Bludsworth Absentee Election Manager P. O. Box 1350 Ozark AL 36361 334‐774‐5993 Dallas County Cheryl Curtis Strong Absentee Election Manager P. O. Box 327 Selma AL 36702 334‐874‐2525 DeKalb County Pam Bailey Simpson Absentee Election Manager P. O. Box 681149 Fort Payne AL 35968 256‐845‐8525 Elmore County Larry Dozier Absentee Election Manager P. O Box 310 Wetumpka AL 36093 334‐514‐3129 Escambia County James K. Taylor Absentee Election Manager P. O. Box 856 Brewton AL 36427 251‐867‐0225 Etowah County Billy Yates Absentee Election Manager 801 Forrest Ave. Ste. 202 Gadsden AL 35901 256‐549‐2181 Fayette County Juston E. Smith Absentee Election Manager P. O. Box 906 Fayette AL 35555 205‐932‐4617 Franklin County Anita Scott Absentee Election Manager P. O. Box 160 Russellville AL 35653 256‐332‐8861 Geneva County Gale Laye Absentee Election Manager P. O. Box 86 Geneva AL 36340 334‐684‐5620 Greene County Etta B. Edwards Absentee Election Manager P. O. Box 307 Eutaw AL 35462 205‐372‐3598 Hale County Catrinna L. Perry Absentee Election Manager P. O. Box 99 Greensboro AL 36744 334‐624‐4334 Henry County Shirlene B. Vickers Absentee Election Manager 101 Court Square Ste. J Abbeville AL 36310 334‐585‐2753 Houston County Carla H. Woodall Absentee Election Manager P. O. Drawer 6406 Dothan AL 36302 334‐671‐8764 Jackson County William K. Ferrell Absentee Election Manager P. O. Box 397 Scottsboro AL 35768 256‐574‐9320 Jefferson ‐ Bessemer County Earl N. Carter, Jr. Absentee Election Manager 1801 3rd Ave. N. Ste. 606 Bessemer AL 35020 205‐481‐4165 Jefferson ‐ Birmingham County Anne‐Marie Adams Absentee Election Manager 716 Richard Arrington Jr. Blvd. N. Rm. 400 Birmingham AL 35203 205‐325‐5355 Lamar County Mary Ann Jones Absentee Election Manager P. O. Box 434 Vernon AL 35592 205‐695‐7193 Lauderdale County Missy Homan Hibbett Absentee Election Manager P. O. Box 776 Florence AL 35631 256‐760‐5728 Lawrence County Harce Hill Absentee Election Manager P. O. Box 249 Moulton AL 35650 256‐974‐2438 Lee County Corinne T. Hurst Absentee Election Manager 2311 Gateway Dr. Rm. 104 Opelika AL 36801 334‐749‐7141
Absentee Election Managers State of Alabama
Revised 10/03/2008
Limestone County Charles Page, Jr. Absentee Election Manager 200 Washington St. W. Athens AL 35611 256‐233‐6406 Lowndes County Ruby Jones Absentee Election Manager P. O. 876 Hayneville AL 36040 334‐548‐2252 Macon County David Roy Love, Jr. Absentee Election Manager 101 E Rosa Parks Ave. Ste. 300 Tuskegee AL 36083 334‐724‐2614 Madison County Jane C. Smith Absentee Election Manager 100 North Side Sq. Rm. 217 Huntsville AL 35801 256‐532‐3390 Marengo County Rusty Nichols Absentee Election Manager P. O. Box 480566 Linden AL 36748 334‐295‐2224 Marion County Sheila S. Bozeman Absentee Election Manager P. O. Box 1595 Hamilton AL 35570 205‐921‐1943 Marshall County Cheryl Pierce Absentee Election Manager 424 Blount Ave. Ste. 201 Guntersville AL 35976 256‐571‐7785 Mobile County Jo Schwarzauer Absentee Election Manager 205 Government St. Ste. 913 Mobile AL 36644 251‐574‐8806 Monroe County John M. Sawyer Absentee Election Manager 65 N. Alabama Ave. Monroeville AL 36460 251‐743‐2283 Montgomery County Montgomery Election Center Absentee Election Manager Courthouse Annex 2, 125 Washington Ave Montgomery AL 36104 334‐832‐1326 Morgan County John Pat Orr Absentee Election Manager P. O. Box 668 Decatur AL 35602 256‐351‐4790 Perry County Mary C. Moore Absentee Election Manager P. O. Box 505 Marion AL 36756 334‐683‐6106 Pickens County Bobby Cowart Absentee Election Manager P. O. Box 418 Carrollton AL 35447 205‐367‐2050 Pike County Brenda Meadows Peacock Absentee Election Manager 120 W. Church St. Troy AL 36081 334‐566‐5113 Randolph County Chris May Absentee Election Manager P. O. Box 328 Wedowee AL 36278 256‐357‐4551 Russell County Kathy Coulter Absentee Election Manager P. O. Box 518 Phenix City AL 36868 334‐298‐0516 Shelby County Mary H. Harris Absentee Election Manager P. O. Box 1810 Columbiana AL 35051 205‐669‐3760 St. Clair County Annette M. Hall Absentee Election Manager 100 6th Ave. Ste 400 Ashville AL 35953 205‐594‐2184 Sumter County Edmond Bell Absentee Election Manager P. O. Box 936 Livingston AL 35470 205‐652‐2291 Talladega County Clarence E. Haynes Absentee Election Manager P. O. Box 6137 Talladega AL 35161 256‐761‐2102 Tallapoosa County Frank Lucas Absentee Election Manager 125 N. Broadnax St. Rm. 132 Dadeville AL 36853 256‐825‐1098
Absentee Election Managers State of Alabama
Revised 10/03/2008
Tuscaloosa County Margaria H. Bobo Absentee Election Manager P. O. Box 038993 Tuscaloosa AL 35403 205‐349‐3870 Walker County Susan D. Odom Absentee Election Manager P. O. Box 1389 Jasper AL 35501 205‐384‐7268 Washington County Steven Grimes Absentee Election Manager P. O. Box 548 Chatom AL 36518 251‐847‐2239 Wilcox County Ralph W. Ervin Absentee Election Manager P. O. Box 608 Camden AL 36726 334‐682‐4126 Winston County John Snoddy Absentee Election Manager P. O. Box 309 Double Springs AL 35553 205‐489‐5533