Absentee Ballot Application - Fillable

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This is the Town of Centreville Board of Supervisors of Elections application to request an absentee ballot for the Centreville Town Election on October 2, 2023. Applicants must be at least 18, have resided in Centreville for 30 days before the election, and be registered to vote. Regular absentee applications are due by Monday, September 25, 2023 at 4:30 p.m.; emergency absentee requests after that deadline are allowed only for illness or accident, or for a death or serious illness in the immediate family that occurs after the deadline. Applicants must either provide a mailing address for the ballot or designate a registered Centreville voter to hand-deliver it (agent affidavit required), and must sign the form in ink—electronic signatures are not accepted.

absentee ballot Centreville October 2, 2023 election deadline Sept 25 2023 emergency absentee agent delivery Board of Supervisors of Elections signature requirement

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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.
Please sign with a pen. No electronic signatures allowed.
(Signature) (Print Name)
2023 ABSENTEE BALLOT Application Rev. 08/29/2023