Return to:††


†P.O. Box 349

Springview, NE† 68778

Application for Early Voterís Ballot

Date: _________________________________

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.


(†† )†††††† I request ballots be mailed to the following address:




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 Voterís Name: _____________________________†† Agentís Signature___________________________

VOTING:† what a privilege!


Voterís 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



For Office Use Only:


Ballots Assigned: ________________________†††††††††††††††††††††† Application Number: _______________________


Staff Initials: ___________________________††††††††††††††††††††††††† Date Sent: ______________________________


Voter ID Number: ________________________††††††††††††††††††††††† Date Returned: __________________________