Free DECLARATION OF INTENT TO BE A WRITE-IN CANDIDATE (VRG-22) - Indiana

UNIFORMED SERVICES VOTER REGISTRATION CERTIFICATE
State Form 51261 (R/4-04) Indiana Election Commission (IC 3-7-36-14)

(ABS-11)

INSTRUCTIONS: An absent uniformed services voter may register after registration closes and after the poll lists have been prepared if the voter meets the qualifications and provides the documents set forth in IC 3-7-36-14 to the county voter registration office. The voter may then vote in this election by absentee ballot in the office of the circuit court clerk. The county voter registration office issues this certificate certifying that the voter registered under this procedure and delivers the certificate to the circuit court clerk, who attaches this certificate to the voter's absentee ballot envelope. The ballot envelope with attached certificate shall be forwarded to the precinct where the voter is registered. The inspector shall remove this certificate when processing this absentee ballot and shall attach this certificate to the poll list in the presence of the poll clerks and the poll clerks shall sign a statement indicating that the inspector did so.

STATE OF INDIANA COUNTY OF ____________________________________

) ) SS: )

TOWNSHIP OR WARD________________________) ) SS: PRECINCT _________________________________ )

ABSENT UNIFORMED SERVICES VOTER CERTIFICATE
To the inspector of this precinct: This certifies that
Name of Voter Voter's Date of Birth (mm/dd/yy) ________/________/________ City Voter Identification Number

Voter's Registration Address

Zip Code

registered to vote under IC 3-7-36-14 in the precinct where the person resides and for which you serve as inspector. Under IC 3-7-36-14, this voter is entitled to vote in this election by absentee ballot in the office of the circuit court clerk. This certificate is attached to the absentee ballot of a voter who registered to vote, and voted, pursuant to IC 3-7-36-14.
SO CERTIFIED THIS THE __________ DAY OF _____________________________, 20_________.
Circuit Court Clerk Signature

County Board of Voter Registration Signature

County Board of Voter Registration Signature

THE POLL CLERKS ACKNOWLEDGE BY THEIR SIGNATURE BELOW THAT THE INSPECTOR ATTACHED THIS CERTIFICATE TO THE POLL LIST IN THE PRESENSE OF THE POLL CLERKS.
Poll Clerk Signature

Poll Clerk Signature