Return form to:
				Stanton County Clerk/Election Comm 804 Ivy St; PO Box 347 Stanton NE 68779
Application for Early Voter’s Ballot
Date: _________________________ I declare that my voting residence in Nebraska is: ______________________________________________________________________________ (residential address) and that my election precinct is: ___________________________ in Stanton County, Nebraska. I am a qualified elector of the State of Nebraska and will not be going to the polls on the day of said election; therefore I request ballots for the ____________________ Election to be held on ______________________________________. I affiliate with the _________________________ political party. ▢ I request ballots be mailed to the following address: __________________________________________________________________________ The Election Office may reach me at phone number/email address __________________________________________________________________________ to verify any information, which might be required, prior to sending the ballots to me. ▢ I will vote in this office . ▢ I will take my ballots with me and vote at my residence.
___________________________________			_X____________________________________
Print Voter’s Name			Voter’s Signature
Voter’s Birth Date: _______________________			______________________________________
			Agent’s Signature:
			Relationship: _____________________________
The penalty for election falsification is imprisonment for up to five years, or a fine not to exceed $10,000.00 or both **********
For Office Use Only:
Voter ID Number:	__________________	Application Number:			___________________
Ballots Assigned:	__________________	Date Sent:			___________________
Staff Initials:	__________________	Date Returned:			___________________