EARLY VOTING APPLICATION REQUEST

Primary Election May 15^th, 2012 General Election November 6^th, 2012

I, _______________________________________, the undersigned, declare that my voting residence

in Otoe County, Nebraska is:_________________________________________________________,

(Street Address)

_______________________________________________________________________________

(City) (Zip code) (Precinct if known)

As a registered voter in the State of Nebraska, I affiliate with the _________________________ party.

(Or check here _______ if not affiliated with any party)

The ballot(s) should be mailed to me at _______________________________________________

(Complete if different than address listed above)

_______________________________________________________________________________

(City) (State) (Zip Code)

The Election Office may reach me to verify any information prior to sending out the ballot(s) by phone

at : ________________________ or by email at: _________________________________________

________________________________________ ______________________________________

Printed Name of Applicant Date of Application

___________________________________ OR ______________________________________

Signature of Applicant Signature of Relative or Person Acting as Agent (AGENT CAN ONLY ACT FOR TWO VOTERS)

The penalty for election falsification is imprisonment for up to five years, or a fine not to exceed $10,000.00 or both.

Office hours for voting: Monday thru Friday 8:00 a.m. to 4:30 p.m. Early Voting Deadlines 2012

Primary General

Early Ballots should be available for voting the week of: April 9^th October 1st

Last day to apply for ballot to be mailed (4:00 pm): May 9^th October 31^st

Last day to apply for ballot and vote in office: May 14^th November 5^th

Last day for Agent to make application and pick up absentee ballot (7:00 pm): May 15^th November 6^th

All Ballots must be in possession of the County Clerk by 8:00 pm: May 15^th November 6^th

Mail application to: Otoe County Clerk, PO Box 249, Nebraska City, NE 68410.

For further information call: 402-873-9501

FOR OFFICE USE ONLY:

App Rec’d______________ Verified by __ Voter ID ____________ Ballot Type__________ Party _________

Date Sent / Picked up by Agent_____________ or Voted Here________ Application #________ Entered £