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:
Residential address:
Zip Code :
Mailing address (if different than above):
Mailing City:
Mailing Zip Code :
Date of birth:

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: