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Question | Answer |
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Form Name | Form Av1M |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | KS, KSA, False, kansas form av1m |
Ofice of the Kansas Secretary of State
Application for Advance Ballot by Mail |
FORM |
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AV1M |
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DOWNLOAD THIS FORM AT WWW.SOS.KS.GOV |
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1. Afirmation |
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Afirmation of an Elector of the County of ____________________ and State of Kansas Desiring to Vote an Advance Voting Ballot
State of ____________________, County of ____________________, ss: (where application is completed)
2. Voter Identiication Requirements
I understand that my current and valid Kansas driver’s license number or Kansas nondriver’s indentiication card number must be provided in order to receive a ballot.
Current Kansas driver’s license number or nondriver’s identiication card number: ________________________________
If I do not have a current and valid Kansas driver’s license number or Kansas nondriver’s identiication card number, I must provide a copy of one of the following forms of identiication with this application in order to receive a ballot:
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Driver’s license issued by Kansas or another state |
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Employee badge or ID document issued by a government ofice |
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Nondriver’s ID card issued by Kansas or another state |
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U.S. military ID |
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U.S. passport |
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Student ID card issued by an accredited Kansas postsecondary |
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Concealed carry of handgun license issued by Kansas |
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educational institution |
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or another state |
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Public assistance ID card issued by a government ofice |
3. Personal Information Please print. |
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______________________________ |
______________________________ ____ |
__________________________ |
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Last Name |
First Name |
M.I. |
Date of Birth (MM/DD/YY) |
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__________________________________________ |
_______________________ |
__________ |
_____________ |
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Residential Address |
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City |
State |
Zip Code |
Political Party (To be illed in only when requesting a primary election ballot): □ Democratic □ Republican
4. Address to Mail Ballot (if different from residential address)
__________________________________________ |
_______________________ |
__________ |
_____________ |
Mailing Address |
City |
State |
Zip Code |
Note: The ballot may be mailed only to the voter’s residential or mailing address as indicated on the county voter registration list, to the voter’s temporary residential address, or to a medical care facility where the voter resides. These restrictions do not apply to a voter who has an illness, disability or who lacks proiciency in the English language. Ballots cannot be mailed until 20 days before the election.
5.Voter Signature Note: False statement on this afirmation is a severity level 9, nonperson felony.
I do solemnly afirm under penalty of perjury that I am a qualiied elector residing at the address listed above. I am entitled to vote an advance voting ballot and I have not voted and will not otherwise vote at the election to be held on
____________________ (date).
Required |
______________________________ |
______________________________ |
________________________ |
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Signature of Voter |
Date (MM/DD/YY) |
Phone Number |
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FOR OFFICE USE ONLY Date App. Rec’d. ____________ Ballot Mailed ____________ Transmitted by ____________
Prepared by the Ofice of Secretary of State Kris W. Kobach, 1st Floor, Memorial Hall, Topeka, KS
KSA