Return to:††

†KEYA PAHA COUNTY ELECTIONS

†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.

OR

(†† )†††††† 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: __________________________