2023_absentee_ballot_application_-_fillable.pdf

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The Town of Centreville

BOARD OF SUPERVISORS OF ELECTIONS

101 Lawyer’s Row Centreville, Maryland 21617 410-758-1180

APPLICATION FOR ABSENTEE BALLOT

I, (full name) am at least eighteen years of age, have resided within the corporate limits of Centreville for 30 days preceding the Town election, and am registered to vote.

My address of residence is: , Centreville, Maryland 21617 Complete Section A or B, as well as Section C.

I hereby apply for an Absentee Ballot for the Centreville Town Election to be held on October 2, 2023, for the following reason:

A. Absentee ballot application request is due no later than Monday, September 25, 2023, by 4:30 p.m.:

 I will be absent on Election Day from the Town of Centreville for any reason.

{Centreville Code 50-7.A} B. Emergency absentee ballot application request: (Check one)  I will be unable to be present at the polls as a result of illness or accident occurring after the Monday, September 25, 2023, application deadline for absentee ballots. {Centreville Code 50-7.B.1}  I will be unable to be present at the polls because of a death or serious illness in my immediate family of which I became aware after the Monday, September 25, 2023,

application deadline for absentee ballots. {Centreville Code 50-7.B.2} C. Check one:

 I have applied in person, via email, or via mail, and request that the absentee ballot is sent to me at the following address (Please print):

□ Staff Use Only: Applied in person (Initials)  I request that the absentee ballot be hand delivered to me by the following agent, who is registered to vote in the Town of Centreville, hereby designated by me. {Centreville Code 50-7.C} (Agent’s Affidavit is required).

Agent:

I hereby affirm under the penalty of perjury under the laws of Maryland that all of the above statements are true to the best of my knowledge and belief.

(Signature) (Print Name) 2023 ABSENTEE BALLOT Application Rev. 08/29/2023