HomeMy WebLinkAboutCOM 0390.004 2010-2012 8083294786 COUNTY COUNCIL KONA COUNTY COUNCIL KONA 09:18:36 a.m. 10-19-2011 1 /4
w. ter FOR OFFICE USE ONLY i
DOCUMENT NO,
HRS§11-20
ve
App--%lm o t
on for Permanent Absentee 'Tv'roter Ballot
(if you want absentee ballots for only one election year,use a regular absentee mail ballot request form.)
ctf .1® I hereby request ballot instructions in: Q CHINESE []JAPANESE ❑ ILOCANO
CD
Section1l. Print clearly in black ink.Failure to complete all items will prevent acceptance of this application.
SOCIAL SECURITY NUMBER* DATE OF BIRTH i GENDER 'TELEPHONE NUMBERH
E]FEMALE MALE
MONTH DAY YEAR
LAST NAME FIRST NAME i MIDDLE I;AATC) 'i ,T
...1
RFSIDENCE ADDRESS OR D;=SC RI PTION IN HAWAII(P 0,Box,R.R.,S.R.are not acceptable) APT.NO. CITY ZIP CODE
MAILING ADDRESS IN HAWAi I(Street address or Po-Pox) CITY ZIP CODE
?OPTIONAL EMAIL ADDRESS:
Section 111. Permanent Absentee Ballot Request
SIMON
I, hereby affirm,under penalty of law,the following:
rev.
I am requesting to receive absentee ballots permanently.
0� Please mail my ballots to my mailing address in Hawaii,my voter registration mailing address,or to:
ADDRESS C37Y STATE ZIP CODE
I shall be responsible for informing the clerk of any changes to my personal information,including changes to the mailing address for
my absentee ballots;
3 also understand that my permanent voter status will remain in effect unless and until one of the following conditions occur:
(a)If 1 request termination of status in writing;or
(b)if I die,lose my voting rights,or I am otherwise disqualified from voting;or
(c)If I registerto vote in another jurisdiction;or
(d)If my absentee ballot,voter notification postcard,or any other election mail is returned as undeliverable for any reason;or
(e)If I do not return a voter ballot by 6:00 p.m.election day in both the primary and general election of an election year;
I understand that if my permanent absentee voter status is terminated I will be responsible for reapplying for permanent absentee
r status;and
Alt information furnished on this application is true and correct.
SIGNATURE OR MARK OF APPLICANT(Only signature or mark of applicant is acceptable) DATE
comm. No.
WITNESS SIGNATURE(Re quirr.d oils if applicant makes a mark) DATE
Ref. Date
k
ADDRESS OF WITNESS PHONE NO,OF WITNESS
,
*NOTICE:A Social Security Number is recwrec by hoS§11-15 and HR5§15-4.1tis used to prevent fraudulent registration and voting.Failure to furnish this information will prevent acceptance of this application.
Pursuant to HR5§11-2g,the City/County Clerk;r:.av use this anollcation to transfer a voter to the proper precinct to correspond with the address oiven abnve.under Item 6.
8083294786 COUNTY COUNCIL KONG COUNTY COUNCIL KONA 09:21:00 a.m. 10-19-2011 414
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