APPLICATION FOR ADVANCE VOTING BALLOT

Affirmation of an elector of the county of Doniphan, and state of Kansas desiring to vote an advance voting ballot.

STATE OF KANSAS

SS

COUNTY OF DONIPHAN

I do solemnly affirm that I am a qualified elector of the precinct listed below, residing at the address listed below in the county of DONIPHAN, and state of Kansas. I am entitled to vote an advance voting ballot and I have not voted and will not otherwise vote at the election to be held on AUGUST 3, 2004.

VOTER INFORMATION:

NAME                

RESIDENCE       

CITY/STATE/ZIP

WARD/PCT/TWP

POLITICAL PARTY
(Complete only when requesting primary election ballot.)

MAIL BALLOT TO:

VOTER'S SIGNATURE X________________________________________________________
Note: false statement on this affirmation is a severity level 9, non-person felony.

AFFIDAVIT OF ASSISTANCE

NOTE: This affidavit must be completed only by a person who assists a sick, physically disabled or illiterate voter in completing an application.
I hereby declare under penalty of perjury that I have rendered assistance in marking and or transmitting the advance voting application for the above named voter. I further declare that I have not exercised undue influence and have marked the application as instructed by the sick, physically disabled or illiterate voter. Knowing or willfully failing to sign this statement is a class E felony.        K.S.A. 25-1124

PERSON PROVIDING ASSISTANCE

Name       
Residence:
City/State/Zip

Signature _________________________________

REQUEST #      APPLIED     SENT          VIO                    
                                                                                 K.S.A. 25-112d(a)