By requesting a replacement vote-by-mail ballot, I hereby certify that I did not receive a vote-by-mail ballot for this election, or if I did receive a ballot, that ballot has been lost or destroyed.

1. Election

2. Name

3. Date of Birth (*Required)

(eg. 01/31/1900)

4. Residence Address

(Where you live)

5. Mailing Address

(Where you receive your mail)

6. Email Address

7. Phone Number

8. Cross-Over Party

I have declined to disclose a preference for a qualified political party. The below-listed political parties are allowing crossover voting in this election. For this election only, I request a ballot for the following political party (select only one):

Terms

I have not applied for, nor do I intend to apply for, a vote by mail ballot from any other jurisdiction for this election. By submitting this application, I certify under the laws of the State of California that the name and residence address and information I have provided on this application are true and correct.

Only the registered voter himself or herself may apply for a vote by mail ballot. An application for a vote by mail ballot made by a person other than the registered voter is a criminal offense.

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