Application for Early Voter’s Ballot
I, the undersigned, declare that my voting residence in Nebraska is: _______________________________________________________
and that my election precinct is._(circle one) Garfield Custer Mills in Keya Paha County, Nebraska.
I am a qualified elector of the State of Nebraska and will not be going to the polls on the day of said election, therefore I request ballots for the Primary Election to be held on
__May 15, 2018________________.
I affiliate with the _______________________ political party.
The County Clerk or staff member may reach me at ___________________ phone number to verify any information, which might be required, prior to sending the ballots to me.
( ) I will vote in this office as the Early Voting Polling Place.
Print Voter’s Name: _____________________________ Agent’s Signature___________________________
VOTING: what a privilege!
Voter’s Signature:_______________________________ Relationship: ____________________________
The penalty for election falsification is imprisonment for up to five years,
or a fine not to exceed $10,000.00 or both