§ Miss. Code § 23-15-627(untitled)

Distribution of absentee ballot application by registrar; request for absentee
ballot application by certain persons on behalf of an elector; form of application.
The registrar shall be responsible for furnishing an absentee ballot application form to any
elector authorized to receive an absentee ballot. Except as otherwise provided in Section 23-15625, absentee ballot applications shall be furnished to a person only upon the oral or written
request of the elector who seeks to vote by absentee ballot; however, the parent, child, spouse,
sibling, legal guardian, those empowered with a power of attorney for that elector's affairs or
agent of the elector, who is designated in writing and witnessed by a resident of this state who
shall write his or her physical address on such designation, may orally request an absentee ballot
application on behalf of the elector. The written designation shall be valid for one (1) year after
the date of the designation. An absentee ballot application must have the seal of the circuit or
municipal clerk affixed to it and be initialed by the registrar or his deputy in order to be utilized
to obtain an absentee ballot. A reproduction of an absentee ballot application shall not be valid
unless it is a reproduction provided by the office of the registrar of the jurisdiction in which the
election is being held and which contains the seal and initials required by this section. Such
application shall be substantially in the following form:
"OFFICIAL
APPLICATION
FOR
ABSENT
ELECTOR'S
BALLOT
I, ________, duly qualified and registered in the ________ Precinct of the County
of ________, and State of Mississippi, coming within the purview of the definition
'ABSENT ELECTOR' will be absent from the county of my residence on election day, or
unable
to
vote
in
person
because
(check
appropriate
reason):
( ) (PRESIDENTIAL APPLICANT ONLY:) I am currently a resident of Mississippi or
have moved therefrom within thirty (30) days of the coming presidential election.
( ) I am an enlisted or commissioned member, male or female, of any component of
the United States Armed Forces and am a citizen of Mississippi, or spouse or dependent
of
such
member.
( ) I am a member of the Merchant Marine or the American Red Cross and am a
citizen
of
Mississippi
or
spouse
or
dependent
of
such
member.
(
of
) I am a disabled war veteran who is a patient in any hospital and am a citizen
Mississippi
or
spouse
or
dependent
of
such
veteran.
( ) I am a civilian attached to and serving outside of the United States with any
branch of the Armed Forces or with the Merchant Marine or American Red Cross, and am a
citizen
of
Mississippi
or
spouse
or
dependent
of
such
civilian.
( ) I am a citizen of Mississippi temporarily residing outside the territorial
limits
of
the
United
States
and
the
District
of
Columbia.
( ) I am a student, teacher or administrator at a college, university, junior or
community college, high, junior high, elementary or grade school, whose studies or
employment at such institution necessitates my absence from the county of my voting
residence or spouse or dependent of such student, teacher or administrator who
maintains a common domicile outside the county of my voting residence with such
student,
teacher
or
administrator.
(
)
I
(
)
I
(
)
will
have
I
am
be
a
outside
temporary
sixty-five
the
or
(65)
county
on
permanent
years
election
physical
of
age
day.
disability.
or
older.
(
) I am the parent, spouse or dependent of a person with a temporary or
permanent physical disability who is hospitalized outside his county of residence or
more than fifty (50) miles away from his residence, and I will be with such person on
election
day.
( ) I am a member of the congressional delegation, or spouse or dependent of a
member
of
the
congressional
delegation.
(
will
) I am required to be at work on election day during the times which the polls
be
open.
I hereby make application for an official ballot, or ballots, to be voted by me at
the
election
to
Mail
eligible
'Absent
Elector's
to
be
held
Ballot'
to
in
me at
vote
________,
the
on
________.
following address
by
________ (if
mail).
I realize that I can be fined up to Five Thousand Dollars ($5,000.00) and
sentenced up to five (5) years in the Penitentiary for making a false statement in
this application and for selling my vote and violating the Mississippi Absentee Voter
Law.
(This
sentence
is
to
be
in
bold
print.)
If you are temporarily or permanently disabled, you are not required to have this
application notarized or signed by an official authorized to administer oaths for
absentee balloting. You are required to sign this application in the proper place and
have a person eighteen (18) years of age or older witness your signature and sign this
application
in
the
proper
place.
DO
NOT
SIGN
WITHOUT
READING.
(This
sentence
is
to
be
in
bold
print.)
IN WITNESS WHEREOF I have hereunto set my hand and seal this the ________ day of
________,
2________.
________________________________________
(Signature
of
absent
elector)
SWORN TO AND SUBSCRIBED before me this the ________ day of ________, 2________.
________________________________________
(Official
TO
BE
SIGNED
BY
authorized
WITNESS
to
FOR
administer
VOTERS
oaths
for
absentee
balloting.)
TEMPORARILY
OR
PERMANENTLY
DISABLED:
I HEREBY CERTIFY that this application for an absent elector's ballot was signed
by the above-named disabled elector in my presence and that I am at least eighteen
(18)
years
of
age,
this
the
________
day
of
________,
2________.
________________________________________
(Signature
CERTIFICATE
of
witness)
OF
DELIVERY
I hereby certify that ________ (print name of voter) has requested that I,
________ (print name of person delivering application), deliver to the voter this
absentee
ballot
application.
________________________________________________
(Signature
of
person
delivering
application)
________________________________________________
(Address of person delivering application)"