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WAYNE CENTRAL SCHOOL DISTRICT ● 6200 ONTARIO CENTER ROAD
P. O. Box 155 ● Ontario Center, New York 14520-0155
APPLICATION FOR ABSENTEE BALLOT
APPLICATION FOR ABSENTEE BALLOT
TO:
School District Clerk
,
WAYNE CENTRAL SCHOOL DISTRICT
6200 Ontario Center Road, Post Office Box 155
,
Ontario Center, New York 14520-0155
I,……………………………………………………..,residing at………………………………………………………….
………………………………………………………………………………………………………………………………..
certify that (1) I am, or will be on the day of the school district election, a qualified voter of the Wayne Central School District, (2) I am, or will be on such date, over eighteen (18) years of age, a citizen of the United States and have or will have resided in the Wayne Central School District for a period of thirty (30) days preceding the date of the school election, and (3) will be unable to appear to vote in person on the day of the school district election for one of the following reasons: (check & complete one of the following)
A. ILLNESS OR DISABILITY
A. ILLNESS OR DISABILITY
….
I will be a patient in a hospital, or
….
Because of illness or physical disability, or
(briefly describe illness or disability & list attending physician’s name)
t.’
… Because my name is recorded at the Board of Elections as a registered-voter who is permanently disabled
B. ABSENCE FROM THE COUNTY OF RESIDENCE
B. ABSENCE FROM THE COUNTY OF RESIDENCE
……. My duties, occupation, business or studies will require me to be outside the ‘~ county of my residence on school election day
If such duties, occupation, business or studies ordinarily require absence from your county of residence, please provide a brief description of them:
If such duties, occupation, business or studies do not ordinarily require absence from your county of residence, please attach a statement of special circumstances which account for your absence.
C. VACATION OUTSIDE THE COUNTY OF MY RESIDENCE
….
I will be on vacation outside of the county of my residence from ……………………to ……………………………………, during which time I will be at the following place(s):
NAME OF EMPLOYER: _________________________________________
IF SELF-EMPLOYED, please attach a statement describing the nature & location of your business
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D. DETENTION IN JAIL
I will be
detained in jail
…..
Awaiting action by a Grand Jury
…..Awaiting Trial
…..After conviction for an offense other than a felony
E. ACCOMPANYING A FAMILY MEMBER WHO IS AN ELIGIBLE VOTER
E. ACCOMPANYING A FAMILY MEMBER WHO IS AN ELIGIBLE VOTER
On the day of the school district election, I am or will be accompanying or with the person named below who is my
… spouse … parent … child
who is, or would be if they were a qualified voter, entitled to apply for the right to vote by absentee ballot, for one of the reasons checked on this application form
NAME OF PERSON YOU WILL BE ACCOMPANYING:
………………………………………………………………………………………
Please attach a brief statement outlining reasons and details of absence:
CERTIFICATION OF APPLICANT FOR ABSENTEE BALLOT
I do hereby declare to the best of my knowledge and belief that the foregoing is a true & correct statement and I understand that if I make a material false statement in the foregoing Application for Absentee Ballot, I shall be guilty of a misdemeanor.
Signature or Mark of Applicant………………………………………….….Date………………..
If A Mark, Signature Of Witness:
…………………………………………………………………………………………………………………………………………………………………………………
PLEASE NOTE:
(1) If you wish to have your absentee ballot mailed to you, this application must be returned by mail or in person to the school district clerk at least (7) seven calendar days before school election day
(2) If you wish to have your absentee ballot mailed to an address other than your legal voting address, please indicate that mailing address below:
(3) If you or someone you designate personally picks up your absentee ballot, this application must be received by the school district clerk not later than 5:00 p.m. on the day prior to school election day
DIRECT QUESTIONS TO THE DISTRICT CLERK @ 315-524-0334
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JES/jes:wp 3/95; 3197;3198