REQUEST FOR MISSOURI ABSENTEE BALLOT I, _________________________________, do hereby request an absentee ballot for the (print name) _________________________________________Election. For identification purposes, the last four digits of my social security number are __________. If the election is a primary election, please print the name of the political party ballot you wish to receive ____________. If you registered by mail and this is your first time voting you must provide a copy of current valid photo identification or a copy of a current utility bill, bank statement, government check, paycheck, or government document that shows your name and address. Reason for requesting an absentee ballot: COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. ______(1) Absence on Election Day from the jurisdiction of the election authority in which registered to vote : Calendar No. ______(2) Incapacity of confinement due to illness or physical disability, including a : person who is primarily responsible for the physical care ofJUDICIAL who is a person SUBPOENA Plaintiff(s) incapacitated or confined due to illness or disability; : -against______(3) Religious belief or practice ______(4) Employment as an election authority, as a member of : an election authority, or by an election authority at a location other than your polling place : ______(5) Incarceration, provided all qualifications for voting are retained Defendant(s) : ...................................................... Address where I am registered to vote: _____________________________________________ THE PEOPLE OF THE STATE OF NEW YORK (Street address) TO _____________________________________________ (City, State, Zip Code) GREETINGS: Address where ballot is to be mailed: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before _____________________________________________ the Honorable at the Court located at (Street address) County of in room , on the day of , 20 , o'clock in the _____________________________________________ inat action on the part of thenoon, and at any recessed or adjourned date, to testify and give evidence as a witness this (City, State, Zip Code) Telephone number: _________________________________ subpoena is punishable as a contempt of court and will make you liable to Your failure to comply with this (Include area party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a the code) result of your failure to comply. I do solemnly swear that all statements made on this application are true to the best of my knowledge and Witness, Honorable , one of the Justices of the belief. Court in County, day of ________________________________________________ Signature of Registered Voter , 20 ______________ Date (Attorney must sign above and type name below) Mail this completed form to your local election authority. The appropriate address can be found on the Missouri Secretary of State’s web site. Missouri law requires that requests for absentee ballots must be received by 5:00 p.m. on the Wednesday prior to Election Day if the ballot is to be mailed. The deadline for absentee voting in person in the office of the election authority is 5:00 p.m. on theAttorney(s) for election. If you registered by day before the mail and this is your first time voting you must provide a copy of current valid photo identification or a copy of a current utility bill, bank statement, government check, paycheck, or government document that shows your name and address. §§ 115.279, 115.284.5 PL 107-252 Office and P.O. Address (4/03) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com ,