Application to Provide Vote-By-Mail Ballot to Representative

Application to Provide Vote-By-Mail Ballot to Representative
If a voter needs a second vote-by-mail ballot, the voter may apply in writing for a vote-by-mail ballot to be provided to the voter’s representative. This application must be provided in person to the Marin County Elections Office by the voter’s representative.

The voter’s signature(s) on this application must compare with their voter registration, otherwise a ballot cannot be issued.
Registered Name:*

First NameMiddle NameLast Name
Date of Birth:*

MonthDayYear
Residence Address (do not use a PO Box number):*

Street Address

Street Address Line 2

CityState

Zip Code
Daytime Phone Number:*
Please enter a valid phone number.
Authorization:*

I declare under penalty of perjury that I failed to receive, lost, or destroyed my original ballot. This information is true and correct and I authorize the bearer of this request to pick up my ballot and deliver it to me.
Written Signature of Applicant:
This field is to be filled in manually after the form is printed.
Your signature (or signature variations if more than one) must compare with your voter registration.

Warning: Perjury is a felony, punishable by imprisonment in state prison for up to four years. (Penal Code § 126).
Date Signed:

MonthDayYear
For Official Use Only
Signature of Authorized Representative (to be signed in the presence of the election official):
Acknowledgement of receipt of ballot.
This application cannot be used by groups, organizations, or individuals distributing Vote by Mail applications. There is a special format required by law (Election Code §3007) that is available at your local Registrar of Voters.

This application is provided pursuant to California Election Code §3009, §3021, and §3014 as amended by AB 2608 (2022).

County of Marin Registrar of Voters/Elections Department
3501 Civic Center Drive, Suite 121, San Rafael, CA 94903
MarinVotes.org
(415) 473-6456
Should be Empty:

Application to Provide Vote-By-Mail Ballot to Representative

For Official Use Only