Jefferson County Clerk's Office - Election Center
Absentee Ballot Application Request
   
Your completed application must be received in our office by close of business June 16, 2020.
 
Reason for request: Medical Emergency {COVID-19} (R)
Fields marked with an asterisk are required.
Select Application/Ballot Delivery Method:     
Last four digits of voter's Social Security Number:*
First Name:*
Middle Name:*
Last Name:*
Suffix: 
Voter's Date of Birth:*    M/D/YYYY
   
Mailing (Street) Address*
(Please include: Apt, City, State, Zip Code, Country) 
 
 
   
Requestor's Name:*
Relationship to voter:*
Contact Phone: 
Not required; will be used only if we have problems with your request

 
Fax Number:

We are allowed to use your e-mail address only to contact you regarding elections;
we are strictly prohibited from releasing your e-mail address, for any reason.
 
E-Mail Address:
Confirm E-Mail Address: