Mail-In Ballot Request

You may use this form if you are registered to vote in the District of Columbia and you will be away during an election

All registered voters will automatically receive a ballot at their mailing address.

You DO NOT have to request a mail-in ballot unless you will be away from your DC residence during the election.

Please check this box to proceed

I want my ballot sent to a location other than my registered or mailing address.

ELECTIONS FOR WHICH YOU ARE REQUESTING A BALLOT*

November 5, 2024 General ElectionPlease put me on the PERMANENT MAIL-IN BALLOT LIST so that an absentee ballot will be sent to me in all future elections in which I am eligible to vote. I understand that I will be removed from this list if: a) I submit a written request to be removed; b) I become ineligible to vote for any reason; c) any mail sent to me by the Board of Elections is returned undeliverable for any reason; or d) I fail to vote by mail in two back-to-back elections in which I am eligible to vote.

Name (First, Middle, Last)*

Date of Birth*

MonthDayYear

Telephone No.

Please enter your phone number

Email

DC DMV-issued ID Number*

(or Last Four Digits of Social Security Number)

Current DC Residence Address (P.O. Boxes will not be accepted)*

Please note that if you provide a residence address that is different from the registration address in the Board's records, this application will be considered a request for a change of address.

Ballot Mailing Address (your ballot will be mailed to this address)*

Absentee address, city, and zip code

VOTER DECLARATION/CERTIFICATION:

I swear or affirm, under penalty of perjury, that: the information on this form is true, accurate, and complete to the best of my knowledge; I am a registered voter in the District of Columbia who is eligible to vote in the election(s) for which I have requested a mail-in ballot; and I am not requesting a mail-in ballot or voting in another U.S state or territory. I understand that if I sign this form knowing that the information provided is untrue, I can be convicted and fined up to $10,000 and/or jailed up to five years.

Signature*

Date*

Is someone helping you to complete this form?*

YesNo

ASSISTANT DECLARATION/CERTIFICATION (Required If Applicant Had Help):

I hereby attest that I am unable to sign my name due to illness, injury, or disability. I have read or received assistance to read, and understand, the statements on this form, and I hereby swear or affirm that the statements on this form are true.

Signature or other indicator of voter's signature

Date

Name and address of assistant

Phone number of assistant

Please enter a valid phone number.

Signature of assistant

Date