North Carolina Absentee Ballot Request Form

November 3, 2020 Contact information for your local county

Read instructions before completing this form. boards of election can be found on pages
three and four of this form.
Voter Last Name First Name
Information
Required 1 Middle Name Suffix (Jr, Sr, II, III, IV)
Former Name (If name has changed)

Voter Date of Birth ALSO: Either NC Driver's License/NC DMV ID Number

Identification 2
Required Or Last four digits of voter's Social Security number

If you have lived at this address less than 30 days, when did you move here? (MM/DD/YYYY)
Street
Your NC
Residential City State Zip Code County
Address 3 If you do not receive mail at this address, provide your full mailing address:
Required
Mailing Address

If you leave this section blank, your ballot will be sent to your mailing address, or if none is listed, to your residential
Where do you address above.
want your 4 Street
ballot mailed?
City State Zip Code

We will use your contact information if we have a question about this request.
Contact
Information 5 Phone Email

Requesting an If you are a voter’s near relative or legal guardian and are requesting an absentee ballot for that voter, provide your
absentee ballot name, address and relationship to the voter (see instructions). Also, you must sign in Section 9 below.
for a relative?
If yes, provide the 6 Near relative or Legal
information
Guardian’s name (print) Relationship to Voter
required Address City State Zip Code
Complete this section if you are assisting a voter who is blind, disabled, or unable to read or write, but are not a near
Are you relative or legal guardian. The voter must sign or make their mark. (If a MAT assisted, complete this section.)
helping a voter
complete this Assistant’s full name (print below): Assistant's address:
form?
If yes, you are 7
required by law to If the voter is a patient in a hospital, clinic, nursing home or rest home and the voter needs assistance with
complete this
voting and returning the ballot, provide the name and address of the hospital or facility here:
section.

Member of the Uniformed Services or Merchant I would like my ballot delivered to my:
Marine on active duty or eligible spouse/
dependent Email or Online
If you are Mailing address
Military and/or U.S. citizen outside the United States
Overseas 8
Address where you are stationed or living overseas:
(UOCAVA)
Fax number:

Voter sign and date here Near relative or Legal Guardian (if applicable) sign and
Signature date here
9
Required
X ________________________ Date
x____________________________ Date

Continued Check if you would like to request absentee ballots for other possible elections in 2020 due to your
Request 10 continued or expected illness or disability.
FRAUDULENTLY OR FALSELY COMPLETING THIS FORM IS A CLASS I FELONY UNDER CHAPTER 163 OF THE NC GENERAL STATUTES
 North Carolina Absentee Ballot Request Form Instructions
Your county board of elections must receive the The form may be returned by the voter, the voter’s near relative or
completed and signed absentee request form by verifiable legal guardian, or a Multipartisan Assistance Team:
 In-person to the county board of elections;
5:00 p.m. on Tuesday October 27, 2020.
 By U.S. Postal Service, DHL, FedEx, or UPS; or
 By email or fax.

1 The name you give on this form will be used to update your voter record.

You must provide your date of birth AND one of the following as a form of identification:
2  North Carolina driver license number or NC DMV issued identification card number
 Last four digits of your Social Security number

You will receive a ballot based on where you will have resided for 30 or more days before election day. If you are
temporarily living away from home due to coronavirus or hurricane displacement, or are otherwise away or displaced, but
you have not abandoned your place of residence, and you intend to return, you are not considered to have lost your
3 place of residence. If you have abandoned your place of residence and intend to stay at your new residence indefinitely,
you should register at your new residence. Be sure to include the address where you want your ballot sent in section 4 if
you will be away from your residential or mailing address. If you have moved within your county, you may use this
form to update your residential address and/or your mailing address.

If you do not complete this section, your ballot will be sent to your mailing address. If no mailing address is listed, it will
4 be sent to your residential address. If you want the ballot sent to your mailing address, please provide the address even if
you think we have it in your voter record.

Please provide the information for the voter, and if you are a near relative or legal guardian requesting on behalf of the
5
voter, please provide your information, too.

A near relative or legal guardian may request a ballot on behalf of the voter. All voters are entitled to assistance from
their near relative or verifiable legal guardian. A near relative is the voter’s:
6 spouse parent grandparent mother-in-law
brother child grandchild father-in-law
sister stepchild stepparent son/daughter-in-law
A voter cannot receive assistance from someone else unless the voter is blind, disabled, or unable to read or write.

Assistance for voters who are blind, disabled, or unable to read or write
If a voter cannot complete the absentee request form due to blindness, disability, or inability to read or write, they may
receive assistance from a near relative or legal guardian. If a near relative or legal guardian is not available, someone
else can give assistance. That person must provide their name and address in Section 7.

Assistance for voters who are patients in a hospital, clinic, nursing home, or adult care home (“facility”)
If a voter is a patient in a facility in North Carolina, a member of a Multipartisan Assistance Team (MAT) authorized
7 by the county board of elections can assist the voter. Contact the county board of elections to request assistance from a
MAT.
 It is unlawful for any owner, manager, director or employees of the facility other than the voter's near relative,
verifiable legal guardian, or member of a MAT to request an absentee ballot on behalf of a voter.
 If neither the voter’s near relative or verifiable legal guardian is available, and a MAT is not available within 7
calendar days of a request, the voter may obtain assistance from anyone who is not:
 An owner, manager, director, or employee of the facility
 An elected official, a candidate, or an officeholder in a political party
 A campaign manager or treasurer for a candidate or political party
Complete this section if you claim North Carolina as your voting residence and are:
1. A member of the active or reserve components of the Army, Navy, Air Force, Marine Corps, or Coast Guard of the
United States who is on active duty;
8 2. A member of the Merchant Marine, the commissioned corps of the Public Health Service, or the commissioned
corps of the National Oceanic and Atmospheric Administration of the United States;
3. A member of the National Guard or State militia unit who is on activated status;
4. A spouse or dependent of a member referred to in #1-3;
5. A U.S. citizen currently outside of the United States.

9 This form must be signed by either the voter or the voter’s near relative, or legal guardian.
A typed signature is not acceptable

Check the box if you would like to request absentee ballots for other possible elections in 2020 due to your continued or
10
expected illness or disability.
 ALAMANCE CABARRUS CRAVEN GRAHAM
115 S MAPLE ST PO BOX 1315 406 CRAVEN ST PO BOX 1239
GRAHAM NC CONCORD NC NEW BERN NC ROBBINSVILLE NC
27253-2811 28026-1315 28560-4911 28771-1239
336-570-6755 704-920-2860 252-636-6610 828-479-7969
336-570-6757 (FAX) 704-920-2831 (FAX) 252-636-6687 (FAX) 828-479-4264 (FAX)
ALAMANCE.BOELECTIONS@ CABARRUS.BOE@ CRAVENBOE@ TERESA.GARLAND@
ALAMANCE-NC.COM CABARRUSCOUNTY.US CRAVENCOUNTYNC.GOV GRAHAMCOUNTY.ORG

ALEXANDER CALDWELL CUMBERLAND GRANVILLE

PO BOX 326 PO BOX 564 227 FOUNTAINHEAD LN STE 101 PO BOX 83
TAYLORSVILLE NC LENOIR NC FAYETTEVILLE NC OXFORD NC
28681-0326 28645-0564 28301-5493 27565-0083
828-632-2990 828-757-1326 910-678-7733 919-693-2515
828-632-1381 (FAX) 828-757-1195 (FAX) 910-678-7738 (FAX) 919-690-0245 (FAX)
ELECTIONS@ ELECTIONS@ ABSENTEE@ GRANVILLE.BOE@
ALEXANDERCOUNTYNC.GOV CALDWELLCOUNTYNC.ORG CO.CUMBERLAND.NC.US GRANVILLECOUNTY.ORG

ALLEGHANY CAMDEN CURRITUCK GREENE

PO BOX 65 PO BOX 206 PO BOX 177 110 SE FIRST ST
SPARTA NC CAMDEN NC CURRITUCK NC SNOW HILL NC
28675-0065 27921-0206 27929-0177 28580-1424
336-372-4557 252-338-5530 252-232-2525 252-747-5921
336-372-5435 (FAX) 252-338-1271 (FAX) 252-232-2427 (FAX) 252-747-2426 (FAX)
ALLEGHANYELECTIONS@ ELECTIONS@ CURRITUCK.BOE@ VOTE@
OUTLOOK.COM CAMDENCOUNTYNC.GOV CURRITUCKCOUNTYNC.GOV GREENECOUNTYNC.GOV
ANSON CARTERET DARE GUILFORD
PO BOX 768 1702 LIVE OAK ST STE 200 PO BOX 1000 PO BOX 3427
WADESBORO NC BEAUFORT NC MANTEO NC GREENSBORO NC
28170-0768 28516-1638 27954-1000 27402-3427
704-994-3223 252-728-8460 252-475-5631 336-641-3836
704-694-2443 (FAX) BOEMAIL@ 252-475-1223 (FAX) 336-641-7676 (FAX)
SMELTON@ CARTERETCOUNTYNC.GOV ELECTIONS@ ABSENTEE@
CO.ANSON.NC.US DARENC.COM GUILFORDCOUNTYNC.GOV
ASHE CASWELL DAVIDSON HALIFAX
150 GOVERNMENT CIR STE 2100 PO BOX 698 PO BOX 1084 PO BOX 101
JEFFERSON NC YANCEYVILLE NC LEXINGTON NC HALIFAX NC
28640-8959 27379-0698 27293-1084 27839-0101
336-846-5570 336-694-4010 336-242-2190 252-583-4391
336-846-5574 (FAX) 336-694-9924 (FAX) 336-242-2199 (FAX) 252-583-1068 (FAX)
JOHNSHEPERD@ ELECTIONS@ DAVIDSON.BOE@ ELECTIONS@
ASHECOUNTYGOV.COM CASWELLCOUNTYNC.GOV DAVIDSONCOUNTYNC.GOV HALIFAXNC.COM

AVERY CATAWBA DAVIE HARNETT

PO BOX 145 PO BOX 132 161 POPLAR ST STE 102 PO BOX 356
NEWLAND NC NEWTON NC MOCKSVILLE NC LILLINGTON NC
28657-0145 28658-0132 27028-2148 27546-0356
828-733-8282 828-464-2424 336-753-6072 910-893-7553
828-733-8283 (FAX) 828-464-9832 (FAX) 336-751-0185 (FAX) 910-893-4655 (FAX)
SHEILA.OLLIS@ ELECTIONS@ TPARRISH@ HARNETTBOE@
AVERYCOUNTYNC.GOV CATAWBACOUNTYNC.GOV DAVIECOUNTYNC.GOV HARNETT.ORG
BEAUFORT CHATHAM DUPLIN HAYWOOD
PO BOX 1016 PO BOX 111 PO BOX 975 63 ELMWOOD WAY STE A
WASHINGTON NC PITTSBORO NC KENANSVILLE NC WAYNESVILLE NC
27889-1016 27312-0111 28349-0975 28786-5829
252-946-2321 919-545-8500 910-296-2170 828-452-6633
252-974-2962 (FAX) 919-542-6430 (FAX) 910-296-2167 (FAX) 828-452-6750 (FAX)
BEAUFORT.BOE@ ELECTIONS@ DCBOE@ ELECTIONS@
CO.BEAUFORT.NC.US CHATHAMNC.ORG DUPLINCOUNTYNC.COM HAYWOODCOUNTYNC.GOV

BERTIE CHEROKEE DURHAM HENDERSON

PO BOX 312 40 PEACHTREE ST PO BOX 868 PO BOX 2090
WINDSOR NC MURPHY NC DURHAM NC HENDERSONVILLE NC
27983-0312 28906-2940 27702-0868 28793-2090
252-794-5306 828-837-6670 919-560-0700 828-697-4970
252-794-5368 (FAX) 828-837-7998 (FAX) 919-560-0688 (FAX) 828-697-4590 (FAX)
ELECTIONS@ CCBOE@ ABSENTEE@ HCELECTIONS@
BERTIE.NC.GOV CHEROKEECOUNTY-NC.GOV DCONC.GOV HENDERSONCOUNTYNC.GOV

BLADEN CHOWAN EDGECOMBE HERTFORD

PO BOX 512 PO BOX 133 PO BOX 10 PO BOX 355
ELIZABETHTOWN NC EDENTON NC TARBORO NC AHOSKIE NC
28337-0512 27932-0133 27886-0010 27910-0355
910-862-6951 252-482-4010 252-641-7852 252-358-7812
910-862-7820 (FAX) 252-482-5920 (FAX) 252-641-1740 (FAX) 252-513-8454 (FAX)
ELECTIONS@ CHOWAN.BOELECTIONS@ ECBOE@ ELECTIONS@
BLADENCO.ORG CHOWAN.NC.GOV EDGECOMBECO.COM HERTFORDCOUNTYNC.GOV
BRUNSWICK CLAY FORSYTH HOKE
PO BOX 2 54 CHURCH ST 201 N CHESTNUT ST PO BOX 1565
BOLIVIA NC HAYESVILLE NC WINSTON-SALEM NC RAEFORD NC
28422-0002 28904-7769 27101-4120 28376-1565
910-253-2620 828-389-6812 336-703-2800 910-875-8751 EXT. 1550
910-253-2618 (FAX) 828-389-3757 (FAX) 336-727-2893 (FAX) 910-875-9084 (FAX)
ELECTIONS@ RHALL@ FCVOTES@ ELECTIONS@
BRUNSWICKCOUNTYNC.GOV CLAYNC.US FORSYTH.CC HOKECOUNTY.ORG

BUNCOMBE CLEVELAND FRANKLIN HYDE

PO BOX 7468 PO BOX 1299 PO BOX 180 PO BOX 152
ASHEVILLE NC SHELBY NC LOUISBURG NC SWAN QUARTER NC
28802-7468 28151-1299 27549-0180 27885-0152
828-250-4200 704-484-4858 919-496-3898 252-926-4194
828-250-6262 (FAX) 704-484-4958 (FAX) 919-496-7418 (FAX) 252-926-3707 (FAX)
ELECTIONS@ CLEVELAND.BOE@ MCHAVIS@ ELECTIONS@
BUNCOMBECOUNTY.ORG CLEVELANDCOUNTY.COM FRANKLINCOUNTYNC.US HYDECOUNTYNC.GOV
BURKE COLUMBUS GASTON IREDELL
PO BOX 798 PO BOX 37 PO BOX 1396 203 STOCKTON ST
MORGANTON NC WHITEVILLE NC GASTONIA NC STATESVILLE NC
28680-0798 28472-0037 28053-1396 28677-5245
828-764-9010 910-640-6609 704-852-6005 704-878-3140
828-764-9011 (FAX) 910-640-0916 (FAX) 704-852-6011 (FAX) 704-832-2312 (FAX)
BURKE.BOE@ COLUMBUS.BOE@ ELECTIONS@ BGALLIHER@
BURKENC.ORG COLUMBUSCO.ORG GASTONGOV.COM CO.IREDELL.NC.US
GATES JACKSON
NC COUNTY BOARDS OF PO BOX 621
GATESVILLE NC
401 GRINDSTAFF COVE RD
SYLVA NC
27938-0621 28779-3250
ELECTIONS CONTACT 252-357-1780
252-357-4341 (FAX)
828-586-7538
828-586-1951 (FAX)
INFORMATION (A–J) ELECTIONS@
GATESCOUNTYNC.GOV
ABSENTEE@
JACKSONNC.ORG
 JOHNSTON MOORE POLK TRANSYLVANIA
PO BOX 1172 PO BOX 787 PO BOX 253 PO BOX 868
SMITHFIELD NC CARTHAGE NC COLUMBUS NC BREVARD NC
27577-1172 28327-0787 28722-0253 28712-0868
919-989-5095 910-947-3868 828-894-8181 828-884-3114
919-989-5142 (FAX) 910-947-2389 (FAX) 828-894-3565 (FAX) 828-884-8682 (FAX)
ELECTIONS@ ELECTIONS@ POLKBOE@ TRANSYLVANIA.BOE@
JOHNSTONNC.COM MOORECOUNTYNC.GOV POLKNC.ORG TCONC.ORG

JONES NASH RANDOLPH TYRRELL

367 NC HIGHWAY 58 S UNIT B PO BOX 305 1457 N FAYETTEVILLE ST PO BOX 449
TRENTON NC NASHVILLE NC ASHEBORO NC COLUMBIA NC
28585-7787 27856-0305 27203-3957 27925-0449
252-448-3921 252-459-1350 336-318-6900 252-796-0775
252-448-1040 (FAX) 252-459-1371 (FAX) 336-318-6903 (FAX) 252-796-5375 (FAX)
JKING@ ABSENTEE@ ELECTIONS@ ELECTIONS@
JONESCOUNTYNC.GOV NASHCOUNTYBOE.COM RANDOLPHCOUNTYNC.GOV TYRRELLCOUNTY.NET

LEE NEW HANOVER RICHMOND UNION

PO BOX 1443 230 GOVERNMENT PO BOX 1843 PO BOX 1106
SANFORD, NC CENTER DR STE 38 ROCKINGHAM NC MONROE NC
27331-1443 WILMINGTON NC 28403-1963 28380-1843 28111-1106
919-718-4646 910-798-7330 910-997-8253 704-283-3809
919-718-4629 (FAX) 910-798-7295 (FAX) 910-417-4900 (FAX) 704-282-1083 (FAX)
ELECTIONS@ NEWHANOVER.BOE@ RICHMOND.BOE@ UNION.BOE@
LEECOUNTYNC.GOV NHCGOV.COM RICHMONDNC.COM UNIONCOUNTYNC.GOV
LENOIR NORTHAMPTON ROBESON VANCE
PO BOX 3503 PO BOX 603 PO BOX 2159 300 S GARNETT ST STE C
KINSTON NC JACKSON NC LUMBERTON NC HENDERSON NC
28502-3503 27845-0603 28359-2159 27536-4566
252-523-0636 252-534-5681 EXT:679 910-671-3080 252-492-3730
252-523-3472 (FAX) 252-534-1202 (FAX) 910-737-5094 (FAX) 252-430-7370 (FAX)
SHINES@ ELECTIONS@ ROBESON.BOE@ FGILL@
CO.LENOIR.NC.US NHCNC.NET CO.ROBESON.NC.US VANCECOUNTY.ORG

LINCOLN ONSLOW ROCKINGHAM WAKE

PO BOX 977 246 GEORGETOWN RD PO BOX 22 PO BOX 695
LINCOLNTON, NC JACKSONVILLE NC WENTWORTH NC RALEIGH NC
28093-0977 28540-4146 27375-0022 27602-0695
704-736-8480 910-455-4484 336-342-8107 919-404-4040
704-736-8804 (FAX) 910-455-1390 (FAX) 336-342-8228 (FAX) 919-231-5737 (FAX)
LINCOLNBOE@ ONSLOWBOE@ RCBOE@ VOTER@
LINCOLNCOUNTY.ORG ONSLOWCOUNTYNC.GOV CO.ROCKINGHAM.NC.US WAKEGOV.COM
MACON ORANGE ROWAN WARREN
5 W MAIN ST FL 1 PO BOX 220 1935 JAKE ALEXANDER PO BOX 803
FRANKLIN NC HILLSBOROUGH NC BLVD W STE D10 WARRENTON NC
28734-3005 27278-0220 SALISBURY, NC 28147-1176 27589-0803
828-349-2034 EXT:2035 919-245-2350 704-216-8140 252-257-2114
828-349-2557 (FAX) 919-644-3318 (FAX) 704-216-8145 (FAX) 252-257-5232 (FAX)
MTHIBAULT@ VOTE@ ROWAN.BOE@ DEBBIEFORMYDUVAL@
MACONNC.ORG ORANGECOUNTYNC.GOV ROWANCOUNTYNC.GOV WARRENCOUNTYNC.GOV

MADISON PAMLICO RUTHERFORD WASHINGTON

PO BOX 142 PO BOX 464 PO BOX 927 PO BOX 1007
MARSHALL NC BAYBORO NC RUTHERFORDTON NC PLYMOUTH NC
28753-0142 28515-0464 28139-0927 27962-1007
828-649-3731 252-745-4821 828-287-6030 252-793-6017
828-649-0187 (FAX) 252-745-4114 (FAX) 828-287-6140 (FAX) 252-793-5801 (FAX)
MADISON.BOE@ PAMLICO.BOE@ ELECTIONS@ ELECTIONS@
MADISONCOUNTYNC.GOV PAMLICOCOUNTY.ORG RUTHERFORDCOUNTYNC.GOV WASHCONC.ORG

MARTIN PASQUOTANK SAMPSON WATAUGA

PO BOX 801 PO BOX 1797 120 COUNTY COMPLEX RD STE 110 PO BOX 528
WILLIAMSTON NC ELIZABETH CITY NC CLINTON NC BOONE NC
27892-0801 27906-1797 28328-4851 28607-0528
252-789-4317 252-335-1739 910-592-5796 828-265-8061
252-789-4319 (FAX) 252-331-2560 (FAX) 910-592-3918 (FAX) 828-265-8068 (FAX)
VOTE@ BOE@ EDEVANE@ MATTHEW.SNYDER@
MARTINCOUNTYNCGOV.COM CO.PASQUOTANK.NC.US SAMPSONNC.COM WATGOV.ORG
MCDOWELL PENDER SCOTLAND WAYNE
PO BOX 1509 PO BOX 1232 231 E CRONLY ST STE 305 309 E CHESTNUT ST
MARION NC BURGAW NC LAURINBURG NC GOLDSBORO NC
28752-1509 28425-1232 28352-3820 27530-4903
828-659-0834 910-259-1220 910-277-2595 919-731-1411
828-659-3294 (FAX) 910-259-1269 (FAX) 910-277-2928 (FAX) 919-731-1409 (FAX)
ELECTIONS@ PENDERBOE@ ELECTIONS@ ELECTIONS@
MCDOWELLGOV.COM PENDERCOUNTYNC.GOV SCOTLANDCOUNTY.ORG WAYNEGOV.COM

MECKLENBURG PERQUIMANS STANLY WILKES

PO BOX 31788 PO BOX 336 PO BOX 1309 110 NORTH ST STE 315
CHARLOTTE NC HERTFORD NC ALBEMARLE NC WILKESBORO NC
28231-1788 27944-0336 28002-1309 28697-2469
704-336-2133 252-426-5598 704-986-3647 336-651-7339
704-319-9722 (FAX) 252-426-5068 (FAX) 704-986-3798 (FAX) 336-651-7560 (FAX)
ABSENTEE@ HHUNTER@ ABSENTEE@ ELECTIONS@
MECKLENBURGCOUNTYNC.GOV PERQUIMANSCOUNTYNC.GOV STANLYCOUNTYNC.GOV WILKESCOUNTY.NET

MITCHELL PERSON STOKES WILSON

11 N MITCHELL AVE RM 108 331 S MORGAN ST PO BOX 34 PO BOX 2121
BAKERSVILLE NC ROXBORO NC DANBURY NC WILSON NC
28705-6511 27573-5223 27016-0034 27894-2121
828-688-3101 336-597-1727 336-593-2409 252-399-2836
828-688-1651 (FAX) 336-598-0300 (FAX) 336-593-4022 (FAX) 252-399-2838 (FAX)
ROYCENE.JONES@ PERSONBOE@ VOTE@ ELECTIONS@
MITCHELLCOUNTY.ORG PERSONCOUNTYNC.GOV CO.STOKES.NC.US WILSON-CO.COM
MONTGOMERY PITT SURRY YADKIN
PO BOX 607 PO BOX 56 PO BOX 372 PO BOX 877
TROY NC GREENVILLE, NC DOBSON NC YADKINVILLE NC
27371-0607 27835-0056 27017-0372 27055-0877
910-572-2024 252-902-3300 336-401-8225 336-849-7907
910-576-2118 (FAX) 252-830-1157 (FAX) 336-401-8228 (FAX) 336-849-7927 (FAX)
RHONDA.JOHNSON@ PITTELECTIONS@ ELECTIONS@ YCBOE@
MONTGOMERYCOUNTYNC.COM PITTCOUNTYNC.GOV CO.SURRY.NC.US YADKINCOUNTYNC.GOV
SWAIN YANCEY
NC COUNTY BOARDS OF PO BOX 133
BRYSON CITY NC
PO BOX 763
BURNSVILLE NC
28713-0133 28714-0763
ELECTIONS CONTACT 828-488-6177
828-488-6463 (FAX)
828-682-3950
828-682-2209 (FAX)
INFORMATION (J–Y) JALLMAN@
SWAINCOUNTYNC.GOV
BOE@
YANCEYCOUNTYNC.GOV