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Request for Replacement Advance Voting Ballot

REQUEST FOR REPLACEMENT ADVANCE VOTING BALLOT     Z-122-4 (R 12-95)
Office of the Labette County Clerk/Election Officer

I am a resident and a qualified elector residing at the address listed below.
 
I declared that my ballot was: (circle one)       destroyed       spoiled       lost       not received
and that I have not yet voted and will not otherwise vote more than one ballot at the election to be held on _______________________________________
 
 

*Mail ballot to:

(Complete if mailing address is different.)
Name
 
_____________________________
 
_____________________________
Residence
_____________________________
_____________________________
City/State/Zip
_____________________________
_____________________________
Ward/Pct/Twp
_____________________________
_____________________________
Political Party
_____________________________

 
______________________
Date
 
 
X____________________________________________ Signature of Voter
*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 sick, disabled, of illiterate voters.
Note: False statement on this affirmation is a severity level 9, nonperson felony.

FOR OFFICE USE ONLY: Date App. Rec'd _______________________