Return to: Joann M. Fischer

Knox County Clerk

PO Box 166

Center, NE 68724-0166

Application for Early Voter’s Ballot

Date: _________________________________

I, the undersigned, declare that my voting address (residence) in Nebraska is: _______________________________________________________

and that my election precinct is:_____________________________________

in KNOX 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 ______________________ Election to be held on ________________________.

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 request ballots be mailed to the following address:

_______________________________________________________

( ) I personally picked up my ballots at the Knox County Clerk’s Office.

( ) I will vote at the Knox County Clerk’s Office as the Early Voting Polling Place.

Print Voter’s Name: _____________________________ Agent’s Signature_________________________________

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

*********

For Office Use Only:

Ballots Assigned: ________________________ Application Number: _______________________

Staff Initials: ____________________________ Date Sent: ________________________________

Voter ID Number: ________________________ Date Returned: ____________________________