REQUEST FOR PLACEMENT ON

PERMANENT ABSENT VOTER LIST

I hereby request that my name to be placed on the Permanent Absent Voter List for Baroda Township.

I affirm that I meet one or more of the following requirements (check one)

______ I am 60 years of age or older.

______ I am physically unable to attend the polls without the assistance of another.

______ I cannot attend the polls because of the tenets of my religion.

______ I expect to be absent from the community in which I am registered for the entire time the polls are open on election day.

______ I cannot attend the polls because I am confined to jail awaiting arraignment or trial

Date of Birth ____________________________

Full Name ________________________________________

Physical Address __________________________________________

___________________________________________

_______________________________________

Signature

Please return this form to:

Baroda Township

P.O. Box 215

Baroda MI 49101