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    SCC VBM Ballot Request Application

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    pgwodes
    A voter in Santa Clara County is requesting a replacement ballot for the September 14, 2021 special election. The voter provides their name, date of birth, residence address in Palo Alto, California, and mailing address if different for the ballot. The voter signs the application under penalty of perjury that the information provided is true and correct. The application must be received by the county elections official no later than seven days before the election date.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    SCC VBM Ballot Request Application

    Uploaded by

    pgwodes
    38 views1 page
    A voter in Santa Clara County is requesting a replacement ballot for the September 14, 2021 special election. The voter provides their name, date of birth, residence address in Palo Alto, California, and mailing address if different for the ballot. The voter signs the application under penalty of perjury that the information provided is true and correct. The application must be received by the county elections official no later than seven days before the election date.

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    Scc Vbm Ballot Request Application

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    A voter in Santa Clara County is requesting a replacement ballot for the September 14, 2021 special election. The voter provides their name, date of birth, residence address in Palo Alto, California, and mailing address if different for the ballot. The voter signs the application under penalty of perjury that the information provided is true and correct. The application must be received by the county elections official no later than seven days before the election date.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    38 views1 page

    SCC VBM Ballot Request Application

    Uploaded by

    pgwodes
    A voter in Santa Clara County is requesting a replacement ballot for the September 14, 2021 special election. The voter provides their name, date of birth, residence address in Palo Alto, California, and mailing address if different for the ballot. The voter signs the application under penalty of perjury that the information provided is true and correct. The application must be received by the county elections official no later than seven days before the election date.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

     

     FOR OFFICIAL USE ONLY


    Registrar of Voters
    Vote-By-Mail Ballot Application
    NOTE: Under the Voter’s Choice Act, all registered voters in Santa Clara County will automatically be sent a Vote by Mail ballot beginning 29
    days before each election. This application can be used to request a replacement ballot.

    Enter the date of the election and the type of election (Primary, General, or Special). This application must be received by your
    county elections official not later than seven (7) days prior to the date of the election. A ballot will not be sent to you if this
    application is incomplete or inaccurate.

    I HAVE: ✔ FAILED TO RECEIVE LOST DESTROYED MY ORIGINAL BALLOT.


    (If you made a mistake marking your ballot and need a new one,
    you can tear or shred and dispose of your old ballot)

    1. REPLACEMENT BALLOT REQUEST FOR THE:


    9/14/2021 ,
    Special ELECTION.
    Month/Day/Year Type of Election (Primary, General, or Special)

    Karunya Anantha Sethuraman 11/24/1998


    2. PRINT NAME: 3. DATE OF BIRTH:
    First Middle or Initial Last Month/Day/Year

    3648 Bryant St
    4. RESIDENCE ADDRESS:
    Number and Street (P.O. Box, Rural Route, etc. will not be accepted) (Designate N, S, E, W if used)
    Palo Alto CA 94306
    City State Zip Code or Postal Code

    5. MAILING ADDRESS TO SEND BALLOT FOR THIS ELECTION ONLY (IF DIFFERENT FROM ABOVE):
    412 4th Street #1
    Number and Street/P.O. Box (Designate N, S, E, W if used)
    Mamaroneck NY 10543
    City State or Foreign Country Zip Code or Postal Code

    6. TELEPHONE NUMBER (OPTIONAL): 6505217155 6505217155


    Day Evening

    7. THIS APPLICATION MUST BE SIGNED:


    I have not applied for a vote-by-mail ballot from any other jurisdiction for this election. I certify under penalty of perjury under the laws of the State
    of California that the information I have provided on this application is true and correct.

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

    NOTICE
    You have the right to mail or deliver this application directly to your county elections official.
    Returning this application to anyone other than your county elections official may cause a delay that could interfere with your ability to vote.
    If this application is returned by mail, it must be returned directly to your county elections official.
    Only the registered voter himself or herself may apply for a vote-by-mail ballot. An application for a vote-by-mail ballot made by a person other
    than the registered voter is a criminal offense.

    INDIVIDUALS/ORGANIZATIONS/GROUPS DISTRIBUTING THIS APPLICATION


    The format used on this application must be followed by anyone distributing vote-by-mail ballot applications. Failure to conform to this format is a
    crime. Anyone distributing this application may not preprint a mailing address in Item 5.
    Anyone providing this application to a voter must enter their name, address, and telephone number here:

    County of Santa Clara Registrar of Voters


    1555 Berger Drive, Building 2, San Jose, CA 95112
    Toll Free 1 (866) 430-VOTE (8683) – Fax 1 (408) 293-6002 – www.sccvote.org

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