FOR OFFICIAL USE ONLY

California Vote-By-Mail Ballot Application

REV 03/2018

Enter the date of the election and the type of election (e.g., Primary, General, or Special). This application must be received
by your county elections official not later than seven (7) days prior to the date of the election. The date of the election can be
found at www.sos.ca.gov/elections/upcoming-elections/. A ballot will not be sent to you if this application is incomplete or
inaccurate.

1. THIS IS AN APPLICATION FOR A VOTE-BY-MAIL BALLOT FOR THE , ELECTION.

Month/Day/Year Type of Election (Primary, General, or Special)

2. PRINT NAME: 3. DATE OF BIRTH:

First Middle or Initial Last Month/Day/Year

4. RESIDENCE ADDRESS:
Number and Street (P.O. Box, Rural Route, etc. will not be accepted) (Designate N, S, E, W if used)

City Zip Code California County

5. MAILING ADDRESS FOR BALLOT (IF DIFFERENT FROM ABOVE):

If your mailing address is outside of the U.S., and you are a military or overseas voter, re-register at RegisterToVote.ca.gov or
use the Federal Post Card Application at www.fvap.gov.

Number and Street/P.O. Box (Designate N, S, E, W if used)

City State or Foreign Country Zip Code or Postal Code

6. TELEPHONE NUMBER (OPTIONAL):

Day Evening

7. YES, I WANT TO BECOME A PERMANENT VOTE-BY-MAIL VOTER.

By checking this box and by initialing here , I am requesting to become a permanent vote-by-mail voter. A
vote-by-mail ballot will automatically be sent to me in all future elections. I understand that if I fail to vote by mail in four
consecutive statewide general elections, I will need to reapply for permanent vote-by-mail voter status.

8. THIS APPLICATION MUST BE SIGNED.

I have not applied for a vote-by-mail ballot from any other jurisdiction for this election. I certify under penalty of perjury under
the laws of the State of California that the information I have provided on this application is true and correct.

SIGNATURE DATE

Warning: Perjury is a felony, punishable by imprisonment in state prison for up to four years. (Penal Code § 126)

NOTICE

You have the right to mail or deliver this application directly to your county elections official.
Returning this application to anyone other than your county elections official may cause a delay that could interfere with your ability to vote.
If this application is returned by mail, it must be returned directly to your county elections official.
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.

INDIVIDUALS/ORGANIZATIONS/GROUPS DISTRIBUTING THIS APPLICATION

The format used on this application must be followed by anyone distributing vote-by-mail ballot applications. Failure to conform to this format is
a crime. Anyone distributing this application may not preprint a mailing address in Item 5.
Anyone providing this application to a voter must enter their name, address, and telephone number here:
WHO CAN USE THIS APPLICATION the Permanent Vote-By-Mail Voter box and initialing
the line. Any voter can opt out of the permanent vote-
The uniform California Vote-By-Mail Ballot Application can only by-mail status at any time by contacting their county
be used by a registered voter. If you have not already registered elections official directly.
to vote, you can register to vote online on the Secretary of
State’s website at RegisterToVote.ca.gov. You may also pick ITEM 8. Sign and date in this order – month, day, year.
up a Voter Registration Card at your county elections office, No witness or notary required.
library, or U.S. Post Office. Your completed Voter Registration
Card must be submitted online or to your county elections HOW TO SUBMIT THE APPLICATION
office at least 15 days before the election.
Your Vote-By-Mail Ballot Application must be returned to your
To vote by mail, you can use this Vote-By-Mail Ballot county elections official at least 7 days before the election.
Application, use the form in the county voter information guide However, if you become ill or disabled during the final week
you receive in the mail before an election, or contact your before an election, or find that you will be unable to go to
county elections office. County contact information can be your polling place on Election Day, you may request that a
found online at www.sos.ca.gov/elections/ voting-resources/ vote-by-mail ballot be delivered to you by submitting a written
county-elections-offices/. statement, signed under penalty of perjury to your county
elections official. The statement must contain your name and
This Vote-By-Mail Ballot Application is provided by the residence address, the address to which you want the ballot
Secretary of State (SOS) for use by any person, group, or sent, the name and date of the election in which you would
organization distributing vote-by-mail ballot applications for like to vote, your signature, and the date. You may authorize
elections that involve more than one county. For organizations another person to receive the ballot from the elections official,
distributing applications for elections that involve a single and/or return the ballot to an elections official after you have
county, the county elections office should be contacted for the voted it.
appropriate application format and barcode information.
If this application is returned by mail, it must be returned
Californians who are serving in the military and are absent directly to your county elections official.
from the county where they are eligible to vote, and
Californians living or studying abroad may register as a military Please do not send applications to the SOS’s office. Doing so
or overseas voter, either online at RegisterToVote.ca.gov or via will delay the application process.
the Federal Post Card Application (FPCA). Doing so provides
more options for receiving your ballot and ensures priority You can find the address and telephone number of your county
service. The FPCA and other important information for military elections official on the SOS website at www.sos.ca.gov/
and overseas voters is available at www.fvap.gov. elections/voting-resources/county-elections-offices/.
How to Fill Out this Application
WHAT CAN BE PREPRINTED ON THE APPLICATION
ITEM 1. Enter the date of the election in which you
wish to vote (month, day, year), and the type of election State law requires the voter to personally affix his or her
(Primary, General, or Special). signature and the address to which the ballot is to be mailed.

ITEM 2. Print your first, middle, and last names as they If an organization is distributing the application, the name,
appear on your Voter Registration Card. address, and telephone number of the organization authorizing
distribution must be included on the application.
ITEM 3. Print your date of birth in this order – month,
day, year. In order to ensure accuracy, each voter should fill out all of the
information on the application. However, any person, group,
ITEM 4. Print the complete street address of your or organization distributing the application may preprint the
voting residence. A post office box or rural route following:
cannot be accepted.
• The printed name and home address of the voter as it
ITEM 5. Mailing address information must be appears on the Voter Registration Card.
completed by the voter. Print the complete address • The name and date of the election for which the ballot is
where you want your ballot sent if it is different than requested.
the residence address provided in Item 4. • The name, address, and telephone number of the person,
group, or organization authorizing distribution of the
ITEM 6. Print your telephone number (optional, not application.
required) to allow the elections office to contact you if
more information is needed.

ITEM 7. Any registered voter may receive a vote-by-mail

ballot automatically in all future elections by checking

(Revised March 2018)

 CALIFORNIA COUNTY ELECTIONS OFFICES

KINGS PLACER S H A S TA
ALAMEDA
1400 W. Lacey Blvd. P.O. Box 5278 P.O. Box 990880
1225 Fallon Street, Room G-1
Hanford, CA 93230 Auburn, CA 95604 Redding, CA 96099-0880
Oakland, CA 94612
(559) 852-4401 (530) 886-5650 (530) 225-5730
(510) 272-6933
L AKE PLUMAS SIERRA
ALPINE 255 N. Forbes Street 520 Main Street, Room 102 P.O. Drawer D
P.O. Box 158 Lakeport, CA 95453 Quincy, CA 95971 Downieville, CA 95936-0398
Markleeville, CA 96120 (707) 263-2372 (530) 283-6256 (530) 289-3295
(530) 694-2281
L ASSEN RIVERSIDE SISKIYOU
AMADOR 220 S. Lassen Street, Suite 5
2724 Gateway Drive 510 N. Main Street
810 Court Street Susanville, CA 96130 Riverside, CA 92507-0918 Yreka, CA 96097-9910
Jackson, CA 95642 (530) 251-8217 (951) 486-7200 (530) 842-8084
(209) 223-6465
LOS ANGELES
P.O. Box 1024 SACRAMENTO SOLANO
BUTTE
Norwalk, CA 90651-1024 7000 65th Street, Suite A 675 Texas Street,
155 Nelson Ave
(800) 815-2666 Sacramento, CA 95823-2315 Suite 2600
Oroville, CA 95965-3411
(916) 875-6451 Fairfield, CA 94533
(530) 538-7761
MADERA (707) 784-6675
200 W. 4th Street SAN BENITO
C A L AV E R A S
Madera, CA 93637 440 Fifth Street, Room 206 SONOMA
891 Mountain Ranch Road
(559) 675-7720 Hollister, CA 95023-3843 P.O. Box 11485
San Andreas, CA 95249
(831) 636-4016 Santa Rosa, CA 95406-1485
(209) 754-6376
MARIN (707) 565-6800
P.O. Box E SAN BERNARDINO
COLUSA
San Rafael, CA 94913-3904 777 E. Rialto Avenue S TA N I S L A U S
546 Jay Street, Suite 200
(415) 473-6456 San Bernardino, CA 92415-0770 1021 I Street, Suite 101
Colusa, CA 95932
(909) 387-8300 Modesto, CA 95354-2331
(530) 458-0500
MARIPOSA (209) 525-5200
P.O. Box 247 SAN DIEGO
C O NT R A C O S TA Mariposa, CA 95338 P.O. Box 85656 SUTTER
P.O. Box 271 (209) 966-2007 San Diego, CA 92186-5656 1435 Veterans Memorial Circle
Martinez, CA 94553
(858) 565-5800 Yuba City, CA 95993
(925) 335-7800 MENDOCINO
501 Low Gap Road, Rm 1020 (530) 822-7122
SAN FRANCISCO
D E L N O RT E Ukiah, CA 95482
1 Dr. Carlton B. Goodlett Place, TEHAMA
981 H Street, Room 160 (707) 234-6819
Room 48 P.O. Box 250
Crescent City, CA 95531
San Francisco, CA 94102-4635 Red Bluff, CA 96080-0250
(707) 465-0383 MERCED
2222 M Street, Room 14 (415) 554-4375 (530) 527-8190
EL DORADO Merced, CA 95340
(209) 385-7541 SAN JOAQUIN TRINITY
P.O. Box 678001
P.O. Box 810 P.O. Box 1215
Placerville, CA 95667
MODOC Stockton, CA 95201 Weaverville, CA 96093-1258
(530) 621-7480
108 E. Modoc Street (209) 468-2885 (530) 623-1220
Alturas, CA 96101
FRESNO
(530) 233-6205 SAN LUIS OBISPO TULARE
2221 Kern Street
1055 Monterey Street, 5951 S. Mooney Blvd.
Fresno, CA 93721
MONO Room D-120 Visalia, CA 93277
(559) 600-8683 P.O. Box 237 San Luis Obispo, CA 93408 (559) 624-7300
Bridgeport, CA 93517 (805) 781-5228
GLENN (760) 932-5537 TUOLUMNE
516 W. Sycamore Street
SAN MATEO 2 S. Green Street
Willows, CA 95988 MONTEREY 40 Tower Road Sonora, CA 95370-4696
(530) 934-6414 P.O. Box 4400
San Mateo, CA 94402 (209) 533-5570
Salinas, CA 93912
(650) 312-5222
HUMBOLDT (831) 796-1499
VENTURA
2426 6th Street
S A N TA B A R B A R A 800 S. Victoria Avenue,
Eureka, CA 95501 N A PA
1127 1st Street, Ste. E P.O. Box 61510 L-1200
(707) 445-7481
Napa, CA 94559 Santa Barbara, CA 93160-1510 Ventura, CA 93009-1200
(707) 253-4321 (805) 568-2200 (805) 654-2664
IMPERIAL
940 W. Main Street, Suite 206
N E VA D A S A N TA C L A R A YOLO
El Centro, CA 92243
950 Maidu Avenue, Suite 250 P.O. Box 611360 P.O. Box 1820
(442) 265-1060
Nevada City, CA 95959 San Jose, CA 95161-1360 Woodland, CA 95776-1820
(530) 265-1298 (408) 299-8683 (530) 666-8133
INYO
P.O. Drawer F
ORANGE S A N TA C R U Z YUBA
Independence, CA 93526 P.O. Box 11298 701 Ocean St., Room 310 915 8th Street, Suite 107
(760) 878-0224 Santa Ana, CA 92711 Santa Cruz, CA 95060 Marysville, CA 95901-5273
(714) 567-7600 95060-4076 (530) 749-7855
KERN
(831) 454-2060
1115 Truxtun Avenue
Bakersfield, CA 93301
(661) 868-3590

California Secretary of State | (800) 345-VOTE (8683) | www.sos.ca.gov | https://voterstatus.ca.gov