Last Name 2. City Zip Code 5. Organizations distributing this form may not preprint mailing address information. I have not applied for an absentee ballot for this election by any other means. I certify under penalty of perjury under the laws of the State of California that the name and residence address on this application are true and correct.
Perjury is punishable by imprisonment in state prison for two, three or four years.
A spouse or nonspousal primary caregiver, who resides with a voter described above, may also apply. If you are eligible to be a permanent absentee voter please mark an X in the box. You have the legal right to mail or deliver this application directly to the local elections official where you reside.