Request Replacement Vote-by-Mail Ballot

 

To request a replacement vote-by-mail ballot, simply complete the following form, then print and return it to our office using the instructions provided on the printed form. California law requires your original signature to appear on a request for a replacement ballot.

Untitled Document

Full name:
Date of birth:
Residential address:
City:
Zip Code :
Phone:

I declare under penalty of perjury that:

I have not received my original ballot. If I receive another ballot, I will destroy it.

I lost my original ballot. If I find it, I will destroy it.

My original ballot has been damaged or destroyed.

Other, please explain: