文档介绍：FRAUDULENTLY OR PLETING THIS FORM IS ACLASS I FELONY UNDER CHAPTER 163 OF THE NC GENERAL STATUTES. I am requesting an absentee ballot for the: on . Election Type (Primary, General, Municipal, Special, etc.) Election Date Voter Information Last Name First Name Middle Name Suffix Date ofBirth Home Address (NC Residential Address.) Mailing Address (If different than home address.) City State Zip Code City State Zip Code Have you lived at this address for more than 30 days? Yes No County ofResidence Previous Name (ifapplicable) If “No,” indicate the date of your move: _____ /_____ / _____ You must provide at least one identification number below. (or see instructions) Voter Registration No. Phone (optional) Email (optional) NC License or IDNumber SSN X X X?‐? X X?‐? Absentee Voting Information Absentee Mailing Address (Where should the ballot be mailed?) City State Zip Code If voter isregistered as Unaffiliated and requesting aballot for apartisan primary, choose aprimary ballot preference. Democratic Republican Libertarian Non ‐ partisan If voter is apatient in ahospital, clinic, nursing home or rest home ,please indicate whether you will need assistance inmarking your ballot. Yes No If“Yes,” wh at isthe name and address ofthe hospital or facility: Ifrequesting an absentee ballot on behalf of anear relative, list your name, address, contact information and relationship to the vote