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Request Replacement Ballot


Full name:
Date of birth:
Residential address:
Zip Code :
My mailing address is the same as my residential address
Mailing Address (if different than residential address; please include full address including city):
Mailing City, State Zip:

I declare under penalty of perjury that:

I have not received my original ballot. If I receive another ballot, I will destroy it.

I lost my original ballot. If I find it, I will destroy it.

My original ballot has been damaged or destroyed.

Other, please explain: