Form Av1M PDF Details

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Form NameForm Av1M
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesKS, KSA, False, kansas form av1m

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Ofice of the Kansas Secretary of State

Application for Advance Ballot by Mail





1. Afirmation


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:

Driver’s license issued by Kansas or another state

Employee badge or ID document issued by a government ofice

Nondriver’s ID card issued by Kansas or another state

U.S. military ID

U.S. passport

Student ID card issued by an accredited Kansas postsecondary

Concealed carry of handgun license issued by Kansas


educational institution


or another state

Public assistance ID card issued by a government ofice

3. Personal Information Please print.






______________________________ ____


Last Name

First Name


Date of Birth (MM/DD/YY)






Residential Address




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



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).





Signature of Voter

Date (MM/DD/YY)

Phone Number


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 66612-1594.

KSA 25-1122d(a). Rev 10/20/11 jdr