Request Replacement Vote-by-Mail Ballot

 

To request a replacement vote-by-mail ballot, simply complete the following form. 

Full name:
Date of birth:
Residential address:
City:
Zip Code :
My mailing address is the same as my residential address

Mailing Address (if different than residential address; please include full address including city):

Mailing City, State Zip:
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: