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CHERRY COUNTY CLERK

P O BOX 120

VALENTINE NE 69201

(Mail application separate from ballots)

Application for Early Voting/Absent Voter’s Ballot

Date: ______________________

I, the undersigned, declare that my voting residence in Nebraska is:

____________________________________________________________________________________

and that my election precinct is ________________________________ in Cherry County, Nebraska.

I am a qualified elector of the State of Nebraska and will not be going to the polls on the day of said election. Therefore, I request ballots for the Primary Election to be held on May 11, 2010.

I affiliate with the __________________________________political party.

( ) I am voting at the Courthouse today as an Early Voter.

( ) I/My Agent will pick up my ballots.

( ) I request ballots to be mailed to the following address:

____________________________________________________________________________________

Print Voter’s Name: _______________________________ Agent’s Signature:_________________________

Voter’s Signature: _________________________________ Relationship: _____________________________

The penalty for election falsification is imprisonment for up to five years,

Or a fine not to exceed $10,000.00 or both

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VOTING: what a privilege!