TOWN OF CHEVERLY, MARYLAND Mail-In Ballot Request Fillable Form VOTER INFORMATION Name: As it Appears on Voter Registration * Date of Birth (mm/dd/yyyy) * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year18941895189618971898189919001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039 Mailing Address * Cheverly Ward (1 – 6) * - Select -123456 Phone Number * Email Address * Preferred Contact Methods * Email Phone Call Text (Check all that apply) ____________________________________________________________________________________________ You must be registered to vote to request a mail-in ballot. I am Registered to Vote in: * Maryland Town of Cheverly ____________________________________________________________________________________________ DELIVERY INSTRUCTIONS: * Mail to the address above Mail to a different address, designated below: I will pick up my ballot in-person My ballot will be picked up in-person by the following designated agent: Mail to a Different Address, Designated Below: (Enter N/A if Not Applicable) * My Ballot will be Picked Up In-Person by the Following Designated Agent: (Enter N/A if Not Applicable) * ____________________________________________________________________________________________ I hereby affirm under penalty of perjury under the laws of Maryland that all of the above statements are true to the best of my knowledge and belief. By typing your name in the box below you acknowledge that you are the person listed in the name space above at the top of this form. * Date of Signing (mm/dd/yyyy) * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 ____________________________________________________________________________________________ This form will be submitted automatically to The Cheverly Board of Elections Supervisors. This form must be received by close of business on April 24, 2023 in order to obtain a mail-in ballot for the May 1, 2023 election. In-person ballot pick-up must be done by April 28, 2023 . ____________________________________________________________________________________________ WARNINGS: Anyone who willfully signs any false application or oath, or who willfully does any act contrary to the terms and provisions of the Cheverly election laws with intent to cast an illegal vote or to aid another in doing so, or who willfully violates any of the provisions of such laws, or who applies for a ballot under any other name than his/her own, shall, upon conviction, be subject to a fine of $100 or to imprisonment for not more than thirty (30) days or to both, in the discretion of the Court. A mail-in ballot will not be sent unless the applicant is registered to vote in elections for the Town of Cheverly. No voter may vote in person once the voter’s mail-in ballot is received and registered by the Cheverly Board of Election Supervisors. Leave this field blank
