Town Clerk
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Town of Myersville
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I, __________, (print name) hereby apply for a Town of Myersville
Absentee Ballot for the election to be held on __________ (date of
election).
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My residence address is __________.
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I am over the age of 18 years, and I have resided within the
corporate limits of the Town of Myersville for __________ (length
of residency).
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I am currently registered to vote in the Town of Myersville.
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I desire that the ballot be sent to me at the following address:
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__________
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I DECLARE, UNDER THE PENALTIES OF PERJURY, THAT THE STATEMENTS
MADE IN THIS APPLICATION ARE TRUE AND CORRECT.
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(Signature of applicant)
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Date
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OATH
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I, ___________________________ (legibly printed name) do hereby
swear or affirm that I am a voter legally qualified to vote in the
Myersville municipal election to be held on _____________ (date of
election), that I am legally registered to vote in the Town of Myersville
as stated on my application for an absentee ballot, that I have not
voted and will not vote elsewhere in this municipal election, and
that I am not disqualified from voting under the laws or ordinances
of the Town of Myersville.
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Absentee Voter's signature
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WARNING: The Myersville Absentee Voting Ordinance provides penalty
for conviction of false application or oath.
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OATH
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I hereby certify under the penalties of perjury that the absentee
voter voting this absentee ballot required assistance by reason of
disability, inability to write, or inability to read the ballot and
has authorized me to mark the ballot in his/her behalf. I also certify
that I am not a candidate who is on that ballot, am not the voter's
employer or an agent of the employer, am not an officer or agent of
the voter's union, and that I assisted the voter in casting his/her
vote only and did not attempt to influence the voter to vote for or
against any candidate or question appearing on the ballot.
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Signature of Assistant
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