APPLICATION FOR EARLY VOTING BALLOT REQUEST

I, _____________________________________________, declare that my voting residence in Nebraska is: _______________________________________, and my election precinct is: _________ in Cheyenne County, Nebraska.

Check here if you have moved within Cheyenne County and your voter registration should be updated to the new address listed above.

I am a qualified elector of the State of Nebraska and will not be going to the polls on Election Day; therefore, I request ballots for the:

___ Primary Election occurring on May 11, 2010

___ General Election occurring on November 2, 2010

___ Special Election occurring on ______________________, 2010

I affiliate with the following political party:

Republican

Democrat

Nonpartisan

I request ballots be mailed to the following address: ____________________________________________.

I will vote in this office as the Early Voting Polling Place.

I will pickup the ballots.

The County Clerk or staff member may reach me at _________________ phone number to verify any information that might be required prior to sending the ballots to me.

Voter’s Signature: ________________________________________________________

Agent’s Signature: ________________________________________________________

Relationship: ______________________________ Date: ___________________

Ballots must be returned to the County Clerk’s Office by 7:00 P.M., on Election Day

The penalty for election falsification is imprisonment for up to five years,

or a fine not to exceed $10,000.00 or both

Is the voter currently in the military or the spouse or dependent of such member? Yes No

Is voter a citizen temporarily outside of the United States or District of Columbia? Yes No

Is voter an overseas citizen? Yes No

Check here if you wish to be placed on the permanent Early Voting request list.