School District Absentee Ballot Application
(for School District Elections, Budget Votes and Referenda)
Please print clearly.
This application may only be used for school district elections by qualified voters who reside in a school district that provides for
personal registration of voters. If the application requests the absentee ballot be mailed, the application must be received by the
district clerk not later than 7 days before the election for which the absentee ballot is sought. Otherwise, the application may be
personally delivered to the district clerk not later than the day before the election. Applications may not be submitted more than 30
days prior to the election. If you are qualified for absentee voting and issued an absentee ballot, the ballot itself must be received by
the school district clerk by 5 p.m. on the day of the election in order to be canvassed.
1
I am requesting, in good faith, an absentee ballot due to (check one reason):
2
absentee ballot(s) requested for the following school district election(s)
3
Last name or surname
Middle initial
Suffix
4
Date of birth
______/ ______/ _______
School district where you reside
Phone number (optional)
Email (optional)
5
Address where you live (residence) street
Apt
City
State
NY
Zip Code
6
Delivery of School District Absentee Ballot (check one)
Deliver to me in person at office of school district clerk.
I authorize (give name): __________________________to pick up my ballot at the office of the school district clerk.
Mail ballot to me at: (mailing address)
street no. street name apt. city state zip code
Applicant Must Sign Below
7
I certify that I am a qualified and registered voter. I hereby declare that the foregoing is a true statement to the best of my
knowledge and belief, and I understand that if I make any material false statement in the foregoing statement of
application for absentee ballots, I shall be guilty of a misdemeanor.
Date _____________ Signature of Voter: ____________________________________________
If applicant is unable to sign because of illness, physical disability or inability to read, the following statement must be executed: By
my mark, duly witnessed hereunder, I hereby state that I am unable to sign my application for an absentee ballot without
assistance because I am unable to write by reason of my illness or physical disability or because I am unable to read. I have made,
or have the assistance in making, my mark in lieu of my signature. (No power of attorney or preprinted name stamps allowed.)
Date / / Name of Voter: Mark:
I, the undersigned, hereby certify that the above named voter affixed his or her mark to this application in my presence and I know him
or her to be the person who affixed his or her mark to said application and understand that this statement will be accepted for all
purposes as the equivalent of an affidavit and if it contains a material false statement, shall subject me to the same penalties as if I had
been duly sworn.
Resident or patient of Veterans Health
Administration Hospital
Detention in jail/prison, awaiting trial, awaiting
action by a grand jury, or in prison for conviction
of a crime or offense which was not a felony
Absence from county on election day
Temporary illness or physical disability
Permanent illness or physical disability
Duties related to primary care of one or more
individuals who are ill or physically disabled
Annual election and budget vote
Any election held between these dates: absence begins: ____/ ____/_____ absence ends: _____/ _____/ ______
Budget re-vote
Special district election or referendum
(address of witness to mark)
(signature of witness to mark)
New York State Board of Elections Revision Date: March 9, 2020
Instructions
Who may use this application for a school district absentee ballot?
You may use this application if you are a qualified voter who resides in a school district that provides for
personal registration of voters. You may only apply for an absentee ballot on your own behalf.
If you are unsure whether your district provides for personal registration, please contact your district
clerk. If you reside in a district that does not provide for personal registration, you may contact your
school district to apply for an absentee ballot.
Please note, residents of city school districts of cities with one hundred twenty-five thousand
inhabitants or more are not eligible to use this form.
Who is a qualified voter?
You are qualified to vote in your school district if you are:
• a citizen of the United States;
• at least 18 years of age; and
• a resident of the school district for a period of at least 30 days preceding the meeting or election
at which you seek to vote.
No person shall have the right to register for or vote at any school meeting or election who would not be
qualified to register for or vote at an election in accordance with the provisions of Election Law §5-106.
Information for military voters:
Do not use this application if you are:
• a qualified voter who will be absent from your school district on the day of the election as a
result of actual military service;
• a qualified voter who has been discharged from actual military service within 30 days of the
election in which you seek to vote; or
• the spouse, parent, child, or dependent of a military voter as set forth above who is
accompanying such military voter and who is qualified to vote in the same school district as the
military voter.
If you meet any of the above criteria, you are entitled to special provisions if you apply for a military
ballot. Please contact your school district to receive the appropriate application form.
Information for voters with an illness or disability:
If you check the box indicating your illness or disability is permanent, and you are identified as a
permanently disabled voter by the county board of elections, once your application is approved you will
automatically receive a ballot for each school district election in which you are eligible to vote, without
having to apply again. You may sign the absentee ballot application yourself, or you may make your
mark and have your mark witnessed in the spaces provided on the bottom of the application. Please
note that a power of attorney or printed name stamp is not allowed for any voting purpose.
Where and when to return this application:
If you request that the absentee ballot be mailed to you, your application must be received by the
district clerk for your school district no later than 7 days before the election for which you seek an
absentee ballot. Otherwise, you may personally deliver your application to the district clerk no later
than the day before the election. You may not submit your application more than 30 days prior to the
election.
When your absentee ballot will be sent to you:
If you request that the absentee ballot be mailed to you, the district clerk will mail your ballot by regular
mail no later than 6 days prior to the election. Otherwise, the district clerk will deliver your ballot to
you or your agent, as designated on your application, when you or your agent appears in the district
clerk’s office.
For your ballot to be canvassed, it must be received by the school district clerk by 5 p.m. on the day of
the election.