ALEX PADILLA | SECRETARY OF STATE | STATE OF CALIFORNIA … · 2 days ago · I understand my ballot may not be returned by mail. It must be returned in person to the county elections

ALEX PADILLA | SECRETARY OF STATE | STATE OF CALIFORNIA ELECTIONS DIVISION 1500 11th Street, 5th Floor, Sacramento, CA 95814 | Tel 916.657.2166 | Fax 916.653.3214 | www.sos.ca.gov

August 21, 2020 County Clerk/Registrar of Voters (CC/ROV) Memorandum #20178 TO: All County Clerks/Registrars of Voters FROM: /s/ Reina Miller

Voter Accessibility Coordinator

RE: General Election: California Late Vote-by-Mail Ballot Application Form The Secretary of State’s office has updated the attached California Late Vote-by-Mail Ballot Application for counties and for voters to use. (Elec. Code, § 3021.) A link to the application can be found here: https://elections.cdn.sos.ca.gov/vote-by-mail/pdf/late-vote-by-mail-application.pdf.

This application can be used by a voter who is unable to go to the polls because of conditions resulting from his or her absence from the precinct for an election. This form has been called “Late” because it is to be used after the time for requesting a vote-by-mail ballot has closed. This application shall not be required if the vote-by-mail ballot is voted in the office of the elections official at the time of the request.

The Secretary of State requests that counties accept this application and any other form being used by any county for the purpose of complying with Elections Code section 3021. Please note that it is not the intention for this application to replace any form that is currently being used by counties; however, if a county does not currently have such an application, please feel free to link to this application on your website.

The Secretary of State’s office has also updated the translated application in all nine Voting Rights Act (VRA) languages. The translated application are available here: https://www.sos.ca.gov/elections/voter-registration/vote-mail/vbm-nov2020-general-election/.

If you have any questions, please feel free to contact me at (916) 695-1557 or [email protected].

https://elections.cdn.sos.ca.gov/vote-by-mail/pdf/late-vote-by-mail-application.pdfhttps://elections.cdn.sos.ca.gov/vote-by-mail/pdf/late-vote-by-mail-application.pdfhttps://www.sos.ca.gov/elections/voter-registration/vote-mail/vbm-nov2020-general-election/https://www.sos.ca.gov/elections/voter-registration/vote-mail/vbm-nov2020-general-election/mailto:[email protected]

California Late Vote-by-Mail Ballot ApplicationFOR OFFICIAL USE ONLY

Rev 08/2020

If a voter is not able to vote in person at the polls and does not have a vote-by-mail ballot, the voter may apply in writing for a late vote-by-mail ballot. This application must be provided in person to the county elections official by the voter or the voter’s representative. The late vote-by-mail ballot cannot be issued or returned by mail. The ballot must be returned personally or through the voter’s representative.

1. PRINT NAME:

First Middle or Initial Month/Day/YearLast

2. DATE OF BIRTH:

3. RESIDENCE ADDRESS:

Number and Street (P.O. Box will not be accepted)

City Zip Code California County

On ______________________________, the day of the ______________________________ election, I will be unable to go

to my polling place. I authorize _______________________________________ to obtain my ballot and deliver it to me.

Month/Day/Year Primary/General/Special

Authorized Representative

I understand my ballot may not be returned by mail. It must be returned in person to the county elections official or to any polling place in the county prior to 8:00 p.m. on Election Day.

6. CERTIFICATION:I certify under penalty of perjury under the laws of the State of California that the information I have providedon this application is true and correct.

Signature of Voter (Do Not Print): __________________________________________ Date: ________________________________ If a voter is unable to sign, he or she may make a mark which shall be witnessed.

7. WITNESS (IF APPLICABLE):

Witness Signature: ____________________________________________________

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

4. TELEPHONE NUMBER (OPTIONAL):

5. STATEMENT AND AUTHORIZATION:

Alameda County1225 Fallon St., Rm. G-1 Oakland, CA 94612 (510) 272-6973

Alpine County99 Water St.Markleeville, CA 96120 (530) 694-2281

Amador County810 Court St. Jackson, CA 95642-2132 (209) 223-6465

Butte County 155 Nelson Ave. Oroville, CA 95965-3411 (530) 552-3400(800) 894-7761 (Domestic)

Calaveras County 891 Mountain Ranch Rd. San Andreas, CA 95249 (209) 754-6376

Colusa County 546 Jay St., Ste. 200 Colusa, CA 95932 (530) 458-0500

Contra Costa County555 Escobar St. Martinez, CA 94553 (925) 335-7800

Del Norte County 981 H St., Rm. 160Crescent City, CA 95531(707) 464-7216

El Dorado County 2850 Fairlane Ct.Placerville, CA 95667(530) 621-7480

Fresno County2221 Kern St. Fresno, CA 93721 (559) 600-8683

Glenn County516 W. Sycamore St., 2nd Floor Willows, CA 95988 (530) 934-6414

Humboldt County2426 6th StreetEureka, CA 95501 (707) 445-7481

Imperial County940 W. Main St., Ste. 206 El Centro, CA 92243-2839 (442) 265-1060

Inyo County 168 N. Edwards StreetIndependence, CA 93526 (760) 878-0224

Kern County 1115 Truxtun Ave., First Floor Bakersfield, CA 93301-4639(661) 868-3590(800) 452-8683

Kings County 1400 W. Lacey Blvd. Hanford, CA 93230 (559) 852-4401

Lake County 255 N. Forbes St. Lakeport, CA 95453(707) 263-2372(888) 235-6730

Lassen County220 S. Lassen St., Ste. 5 Susanville, CA 96130 (530) 251-8217

Los Angeles County12400 Imperial Hwy. Norwalk, CA 90650 (800) 815-2666

Madera County 200 W. 4th St. Madera, CA 93637 (559) 675-7720(800) 435-0509

Marin County 3501 Civic Center Dr, Ste. 121 San Rafael, CA 94903(415) 473-6456

Mariposa County4982 10th St.Mariposa, CA 95338 (209) 966-2007

Mendocino County 501 Low Gap Rd., Rm. 1020 Ukiah, CA 95482 (707) 234-6819

Merced County 2222 M St. Merced, CA 95340 (209) 385-7541(800) 561-0619

Modoc County108 E. Modoc St. Alturas, CA 96101 (530) 233-6205

Mono County74 N. School St., Annex I Bridgeport, CA 93517 (760) 932-5537

Monterey County 1441 Schilling Place - North Bldg. Salinas, CA 93901 (831) 796-1499 (866) 887-9274

Napa County1127 First St. Ste. E Napa, CA 94559(707) 253-4321

Nevada County 950 Maidu Ave., Ste. 210Nevada City, CA 95959 (530) 265-1298

Orange County1300 South Grand Ave., Bldg. C Santa Ana, CA 92705(714) 567-7600

Placer County 2956 Richardson Dr. Auburn, CA 95603 (530) 886-5650 (800) 824-8683

Plumas County 520 Main St., Rm. 102, Courthouse Quincy, CA 95971 (530) 283-6256

Riverside County 2724 Gateway Dr. Riverside, CA 92507-0918 (951) 486-7200(800) 773-8683

Sacramento County7000 65th St., Ste. A Sacramento, CA 95823 (916) 875-6451(800) 762-8019

San Benito County440 Fifth St., Second Floor, Rm. 205Hollister, CA 95023-3843(831) 636-4016

San Bernardino County 777 E. Rialto Ave. San Bernardino, CA 92415-1005 (909) 387-8300(800) 881-8683

San Diego County 5600 Overland Ave. San Diego, CA 92123(858) 565-5800 (800) 696-0136

San Francisco County 1 Dr. Carlton B. Goodlett PlaceCity Hall, Room 48San Francisco, CA 94102 (415) 554-4375

San Joaquin County 44 N. San Joaquin St Third Floor, Suite 350Stockton, CA 95202(209) 468-8683(800) 400-5009

San Luis Obispo County1055 Monterey St., Ste. D-120San Luis Obispo, CA 93408(805) 781-5228

San Mateo County 40 Tower Rd. San Mateo, CA 94402(650) 312-5222

Santa Barbara County 4440-A Calle Real Santa Barbara, CA 93110(800) 722-8683(805) 568-2200

Santa Clara County 1555 Berger Dr., Bldg. 2 San Jose, CA 95112(408) 299-8683 (866) 430-8683

Santa Cruz County701 Ocean St., Rm. 310 Santa Cruz, CA 95060-4035 (831) 454-2060(866) 282-5900

Shasta County1643 Market St. Redding, CA 96001(530) 225-5730

Sierra County 100 Courthouse Square, Rm. 11 Downieville, CA 95936-0398 (530) 289-3295

Siskiyou County 510 N. Main St. Yreka, CA 96097-2525(530) 842-8084

Solano County675 Texas St., Ste. 2600Fairfield, CA 94533(707) 784-6675(888) 933-8683

Sonoma County 435 Fiscal Dr. Santa Rosa, CA 95403(707) 565-6800(800) 750-8683

Stanislaus County 1021 I St., Ste. 101 Modesto, CA 95354-2331 (209) 525-5200

Sutter County 1435 Veterans Memorial Cir. Yuba City, CA 95993(530) 822-7122

Tehama County633 Washington St., Rm. 17Red Bluff, CA 96080-0250(530) 527-8190

Trinity County 11 Court St.Weaverville, CA 96093-1215(530) 623-1220

Tulare County 5951 S. Mooney Blvd.Visalia, CA 93277(559) 624-7300

Tuolumne County 2 S. Green St.Sonora, CA 95370-4618(209) 533-5570

Ventura County Hall of Administration, Lower Plaza800 S. Victoria Ave.Ventura, CA 93009-1200(805) 654-2664

Yolo County 625 Court St., Rm. B-05Woodland, CA 95695(530) 666-8133(800) 649-9943(916) 375-6490

Yuba County915 8th St., Ste. 107 Marysville, CA 95901-5273(530) 749-7855

Solicitud de boleta de voto por correo tardía de CaliforniaFOR OFFICIAL USE ONLY

Rev 08/2020

Si un votante no puede votar en persona en las urnas y no tiene una boleta de voto por correo, puede solicitar por escrito una boleta de voto por correo tardía. El votante o su representante debe entregar personalmente esta solicitud al funcionario electoral del condado. La boleta de voto por correo tardía no puede emitirse ni devolverse por correo. La boleta debe ser devuelta personalmente o a través del representante del votante.

1. NOMBRE EN LETRA DE MOLDE:

Primer nombre Segundo nombre o inicial Día/Mes/AñoApellido

2. FECHA DE NACIMIENTO:

3. DOMICILIO RESIDENCIAL:

Número y calle (no se acepta apartado postal)

Ciudad Código postal Condado de California

5. DECLARACIÓN Y AUTORIZACIÓN:

El _____________________________, día de la elección ______________________________, no podré acudir a mi lugar de Día/Mes/Año Primaria/General/Especial

votación. Autorizo a _______________________________________ a obtener mi boleta electoral y entregármela.Representante autorizado

Entiendo que mi boleta electoral no puede ser devuelta por correo. Debe ser devuelta personalmente al funcionario electoral del condado o en cualquier lugar de votación del condado antes de las 8:00 p.m. el día de la elección.

6. CERTIFICACIÓN:Certifico bajo pena de perjurio según las leyes del Estado de California que la información que he proporcionado en esta solicitud es verdadera y correcta.

Firma del votante (no escribir en letra de molde): __________________________________________ Fecha: _____________________Si un votante no puede firmar, puede hacer una marca la cual debe ser atestiguada.

7. TESTIGO (SI CORRESPONDE):

Firma del testigo: ____________________________________________________

Advertencia: El perjurio es un delito grave, punible con la cárcel en una prisión estatal por hasta cuatro años. (Código penal § 126)

4. NÚMERO DE TELÉFONO (OPCIONAL):

加州逾期郵寄投遞選票申請表FOR OFFICIAL USE ONLY

Rev 08/2020

如果選民無法親自至投票站投票，並且沒有以郵寄投遞的選票，則選民可以書面形式申請逾期郵寄投遞選票。此申請表必須由選民或選民代表親自交付給縣選舉官員。逾期郵寄投遞選票無法以郵寄發出或寄回。選票必須由選民或選民代表親自交回。

1. 以正楷填寫姓名：

名字中間名或縮寫月／日／年姓氏

2. 出生日期：

3. 住址︰

街道名稱及門牌號碼（不接受郵政信箱 )

城市郵遞區號加州縣

5. 聲明及授權：

於 _____________________________ 月 ______________________________ 日舉行的投票日，我無法前往投票站。我授權

_______________________________________拿取我的選票並將選票交付給我。我了解我的選票不可用郵件寄回。選票必

須在選舉日晚上 8:00之前，親自交給縣選舉官員或縣內任何投票站。

月／日／年主要 /普通 /特殊

授權代表

6. 證明書：我保證在此申請表中提供的資訊為真實正確的，否則願接受加州法律的偽證罪懲罰。

選民簽名（請勿以正楷簽名）: __________________________________________ 日期：________________________________如果選民無法簽名，他或她可以在證人證明下，於選票上作標記。

7. 證人（若適用）：

證人簽名：____________________________________________________

警告：偽證是重罪，最高可處以四年的監禁。（《刑法典》第 126條）

4. 電話號碼（選填）：

California का देरी से मंगवाया जाने वाला डाक–द्ारा–मतदान मतपत्र आवेदनFOR OFFICIAL USE ONLY

Rev 08/2020

यदि कोई मतिाता चुनाव में व्यक्तिगत रूप से मतिान करने में सक्षम नहीं ह ैऔर उसे डाक–द्ारा–मतिान मतपत्र प्ाप्त नहीं हुआ, तो मतिाता एक िरेी से मंगवाया जाने वाले डाक–द्ारा–मतिान मतपत्र के क्लए क्लक्ित रूप से आवेिन कर सकता ह।ै इस आवेिन को मतिाता या मतिाता प्क्तक्नक्ि द्ारा व्यक्तिगत रूप से जाकर काउंटी के चुनाव अक्िकारी को दिया जाना ज़रूरी ह।ै िरेी से मंगवाया जाने वाले डाक–द्ारा–मतिान मतपत्र को डाक द्ारा जारी या वापस नहीं भेजा जा सकता। इस मतपत्र को व्यक्तिगत रूप से जाकर या मतिाता के प्क्तक्नक्ि के माधयम से वापस भेजा जाना ज़रूरी ह।ै1. नाम प्रंट करें:

प्थम नाम मधय या छोटे अक्षर महीना/दिन/सालकुलनाम

2. जनम ततथि:

3. तनवास का पता:

नम्बर और स्ट्ीट (पोस्ट ऑदिस ्बॉकस को स्वीकार नहीं दकया जाएगा)

शहर क्ज़प कोड California काउंटी

5. वक्तव्य और ्राथिकरण:

_____________________________ को, ______________________________ के चुनाव वाले दिन, मैं अपने मतिान स्थल पर

जाने में असमथ्थ ह।ं मैं _______________________________________ को मेरा मतपत्र प्ाप्त करने और मुझ तक पहुचंाने के क्लए

महीना/दिन/साल प्ाथक्मक/सामानय/क्वशेष

प्ाथक्मक प्क्तक्नक्ि

अक्िकृ त करता/ती ह।ं मैं समझता/ती हं दक मेरा मतपत्र डाक से वापस नहीं भेजा जा सकता। इसका अपनी काउंटी के चुनाव अक्िकारी या अपनी काउटंी क ेदकसी मितान सथल पर चुनाव क ेिदन शाम 8:00 ्बजे से पहले, वयकितगत रूप से लौटाना जाना ज़रूरी है।

6. ्रमाणीकरण:मैं California स्टेट के कानूनों के अिीन झूठी गवाही के जुमा्थने के तहत प्माक्ित करता हं दक मेरे द्ारा इस आवेिन में प्िान की गई जानकारी सतय और सही ह।ै

मतदाता के हसताक्षर (प्रंट ना करें): __________________________________________ तारीख: ________________________________ यिद कोई मिताता हसताकषर करने में असमथथ ह,ै तो वह एक कनशान लगा सकता ह ैकजसे लगाते समय दकसी गवाह का मौजूि होना ज़रूरी है।

7. गवाह (यदद लागू होता है):

गवाह के हसताक् र: ____________________________________________________

चेतावनी: झूठी गवाही िेना एक अपराि ह,ै कजसक ेकलए चार साल तक राजय की जेल में कै ि का िंड िदया जा सकता है। (पीनल कोड § 126)

4. टेलीफोन नंबर (वैकल्पक):































Placer County 2956 Richardson Dr. Auburn, CA 95603 (530) 886-5650(800) 824-8683




























California州遅延郵便投票用紙申込書FOR OFFICIAL USE ONLY

Rev 08/2020

有権者が直接投票所で投票できなくて、郵便投票用紙を持っていない場合は、書面で遅延郵便投票用紙の申し込みができます。この申込書は有権者または有権者代理人より郡の選挙担当官に直接提供されなければなりません。遅延郵便投票用紙は郵便で発行したり返送したりすることはできません。投票用紙は個人的に戻すか、有権者の代理人を通して戻さなければなりません。

1. 氏名は活字体でどうぞ：

名ミドルネームまたはイニシャル月 /日 /年姓

2. 生年月日：

3. 現住所：

番地と通り（私書箱は受け付けません）

市郵便番号 California州の郡

5. 声明および承認：

私は ______________________________選挙の当日 _____________________________日、投票所に出向くことができません。

私は _______________________________________が投票用紙を取得し、私に届けてくれることを承認します。私は投票用

予備 /総 /特別月 /日 /年

正式代理人

4. 電話番号（任意）：

紙は郵便で返送できないことを了解します。投票用紙は選挙日の午後 8 時までに郡の選挙担当官に直接戻すか、郡内の投票所に戻さなければなりません。

6. 証明：

私は California 州法で偽証罪に問われることを承知で、この申込書に記載の情報は事実と相違ないことを証明します。

有権者署名（活字体で記入しないでください）：__________________________________________ 日付：____________________________有権者が署名できない場合は、立会人の下でマークを付けてください。

7. 立会人（該当する場合）：

立会人署名：____________________________________________________

警告：偽証は最高四年の州刑務所収監により処罰可能な重罪です。（刑法第 126条）

ពាក្យសុំសន្លឹកឆ្ន្តឆោះយឺតតាមសំបុតតឆៅរដ្ឋ CaliforniaFOR OFFICIAL USE ONLY

Rev 08/2020

ប�ើអ្នកបោះប្នោតមិនអាចបោះប្នោតបោយផ្ោល់បៅមណ្ឌលបោះប្នោត និងមិនមានសន្លឹកប្នោតបោះតាមសំ�ុតត អ្នកបោះប្នោតអាចោក់ពាកោយសុំជាលាយលក្ខណ៍អកោសរសតមា�់សន្លឹកប្នោតបោះយឺតតាមសំ�ុតតោន។ ពាកោយបនះតតរូវផ្តល់ជូនបោយផ្ោល់ដល់មនន្តរីបោះប្នោតត�ចាំបោនធរីបោយអ្នកបោះប្នោត ឬតំណាងអ្នកបោះប្នោត។ សន្លឹកប្នោតបោះយឺតតាមសំ�ុតតមិនអាចបចញ ឬបផញើតតល�់តាមសំ�ុតតវិញបេ។ សន្លឹកប្នោតតតរូវតតត�គល់ជូនវិញបោយផ្ោល់ ឬតាមរយៈអ្នកតំណាងអ្នកបោះប្នោត។

1. ឆ្ម្ះជាអក្សរពុម្ពធំ៖

នាមខ្លួន ប្មោះកណា្ោល ឬដំ�ូង តខ/ថ្ងៃ/្នោំនាមតតកូល

2. ថ្ងៃខែ្ ន្ំកំឆ�ើត៖

3. អាសយដ្្នសន្ក់ឆៅ៖

បលខ និងផ្លូវ (ត�អ�់សំ�ុតតថត�សណរីយ នលឹងមិនេេួលយកបេ)

េរីតកុង ហោស៊រី�កូដ បោនធរី California

5. ឆសចកី�ខ្្ងការ� ៍និងការផ្តីល់់សិទ្ធិិិអំណាច៖

បៅ _____________________________ថ្ងៃបោះប្នោត ______________________________ ខញ៊ំនលឹងមិនអាចបៅមណ្ឌលបោះប្នោតរ�ស់ខញ៊ំោន

បេ។ ខញ៊ំសូមអនុញ្ោត _______________________________________ បៅយកសន្លឹកប្នោតរ�ស់ខញ៊ ំបហើយត�គល់វាឱោយខញ៊ំ។

ខញ៊ំយល់ថាសន្លឹកប្នោតរ�ស់ខញ៊ំត�តហលជាមិនតតរូវោនបផញើតតល�់តាមសំ�ុតតវិញបេ។ វាតតរូវតតត�គល់ជូនបោយផ្ោល់បៅមនន្តរីបរៀ�ចំការបោះប្នោតត�ចាំបោនធរី ឬបៅមណ្ឌលបោះប្នោតណាមួយបៅក្ន៊ងបោនធរីមុនបមា៉ោង 8:00 លា្ោច បៅថ្ងៃបោះប្នោត។

តខ/ថ្ងៃ/្នោំ �ឋម/េូបៅ/ពិបសស

អ្នកតំណាងបពញសិេ្ិ៖

6. ការបញ្ជាា្ក់៖ខញ៊ំសូម�ញ្ោក់ថា បតកាមបោសពិន័យពរីការសោប្�ំពានតាមចោបា�់រ�ស់រដ្ឋ California រាល់ព័ត៌មានតដលខញ៊ំោនផ្តល់ជូនបៅបលើពាកោយបនះគឺពិតតោកដ និងតតលឹមតតរូវ។

ហត្ថឆល់ខារបស់អ្នកឆោះឆ្ន្ត (កុំឆោះពុម្ព)៖ __________________________________ កាល់បរិឆចឆេទ្ធិ៖ ________________________________ប�ើអ្នកបោះប្នោតមិនអាចចុះហត្ថបលោោនបេ គាត់អាចគូសសញ្ោសមា្ោល់តដលតតរូវ�ញ្ោក់។

7. សក្ស� (ឆបើមាន)៖

ហត្ថឆល់ខារបស់សក្ស�៖ ____________________________________________________

ការតពមាន៖ ការសោប្�ំពាន គឺជា�េឧតកិដ្ឋមួយតដលតតរូវផ្តនា្ោបោសោក់ពន្នាគារក្ន៊ងពន្នាគាររដ្ឋរហូតដល់�ួន្ នោំ។ (តកមតពហ្មេណ្ឌបលខ § 126)

4. ឆល់ែទ្ធិូរសព្ទ (ជាជឆតមើស)៖

캘리포니아 주 추가 우편투표지 신청서FOR OFFICIAL USE ONLY

Rev 08/2020

유권자가 투표소에 직접 방문하여 투표할 수 없고 우편투표지를 소유하고 있지 않다면, 해당 유권자는 서면으로 추가 우편투표지를 신청할 수 있습니다. 신청서는 카운티 선거 관리원에게 유권자나 유권자 대리인이 직접 제출해야 합니다. 추가 우편투표지는 우편으로 발급되거나 반환될 수 없습니다. 투표지는 본인이 직접 반환하거나 유권자 대리인을 통해 반환해야 합니다.

1. 인쇄체 이름:

이름 중간 이름 또는 이니셜 월/일/년성

2. 생년월일:

3. 거주지 주소:

번호 및 거리(우편사서함은 수용되지 않음)

도시 우편번호 캘리포니아 카운티

5. 진술서 및 승인서:

이날 _____________________________, ______________________________ 선거일에, 본인은 투표소에 방문할 수 없습니다.

본인은 _______________________________________가 본인의 투표지를 수령하여 본인에게 전달할 수 있도록 승인합니다.

월/일/년 예비/총/특별

승인 대리인

본인은 본인의 투표지가 우편으로 반환될 수 없다는 사실을 이해합니다. 투표지는 선거일 오후 8:00 이전에 카운티 선거 관리원에게나 가까운 카운티 투표소에 직접 반환되어야 합니다.

6. 확인서:본인은 캘리포니아 주법 위증 처벌 원칙 아래 본 신청서에 제공된 정보가 사실이며 정확하다는 것을 이로써 확인합니다.

유권자 서명(인쇄체로 쓰지 말아 주십시오): __________________________________________ 날짜: ________________________________유권자가 서명할 수 없다면, 그 또는 그녀는 증인 입회 아래 표시를 남길 수 있습니다.

7. 증인(해당하는 경우):

증인 서명: ____________________________________________________

경고: 위증은 최대 사 년간 주 교도소 징역형 처벌을 받을 수 있는 중범죄입니다. (형법 제126조)

4. 전화번호(선택 사항):

Aplikasyon para sa Atrasadong Balota ng Pagboto sa Pamamagitan ng Koreo ng California

FOR OFFICIAL USE ONLY

Rev 08/2020

Kung ang isang botante ay hindi kayang bumoto nang personal sa mga lugar ng botohan at walang balota ng pagboto sa pamamagitan ng koreo, ang botante ay maaaring magharap ng nakasulat na aplikasyon para sa atrasadong balota ng pagboto sa pamamagitan ng koreo. Ang aplikasyong ito ay dapat dalhin nang personal ng botante o ng kinatawan ng botante sa opisyal sa mga halalan ng county. Ang atrasadong balota ng pagboto sa pamamagitan ng koreo ay hindi maaaring iisyu o ibalik sa pamamagitan ng koreo. Ang balota ay dapat ibalik nang personal o sa pamamagitan ng kinatawan ng botante.

1. ILIMBAG ANG PANGALAN:

Unang Pangalan Panggitna o Inisyal Buwan/Araw/TaonApelyido

2. PETSA NG KAPANGANAKAN:

3. DIREKSIYON NG TIRAHAN:

Numero at Kalye (Hindi tatanggapin ang P.O Box)

Lungsod Kodigo Postal County sa California

5. PAHAYAG NG AWTORISASYON:

Sa _____________________________, ang araw ng ______________________________ halalan, hindi ako makakarating sa aking Buwan/Araw/Taon Primarya/Pangkalahatang/Espesyal

lugar ng botohan. Pinahihintulutan ko si _______________________________________ na kunin ang aking balota at ihatid ito Awtorisadong Kinatawan

sa akin. Nauunawaan ko na ang aking balota ay hindi maaaring ibalik sa pamamagitan ng koreo. Ito ay dapat ibalik nang personal sa opisyal sa mga halalan ng county o sa alinmang lugar ng botohan sa county bago ang ika-8 ng gabi sa Araw ng Halalan.

6. SERTIPIKASYON:Pinatutunayan ko sa ilalim ng parusa sa pagbibigay ng hindi totoong sinumpaang pahayag sa ilalim ng mga batas ng Estado ng California na ang impormasyong ibinigay ko sa aplikasyong ito ay totoo at tumpak.

Pirma ng Botante (Huwag Ilimbag): __________________________________________ Petsa: _____________________________Kung ang botante ay hindi makapirma, siya ay maaaring magmarka na dapat masaksihan ng isang tao.

7. TESTIGO (KUNG ANGKOP):

Pirma ng Testigo: ____________________________________________________Babala: Ang pagbibigay ng hindi totoong sinumpaang pahayag ay isang peloni, maparurusahan ng pagkabilanggo sa bilangguan ng estado para sa hanggang apat na taon. (§ 126 ng Kodigo sa Parusa)

4. NUMERO NG TELEPONO (OPSIYONAL):

ใบสมัครรับบัตรเลือกตั้งส�ำหรับกำรลงคะแนนเสียงลำ่ช้ำผ่ำนทำงไปรษณีย์ในรัฐ California

FOR OFFICIAL USE ONLY

Rev 08/2020

หากผู้ลงคะแนนเสียงไม่สามารถมาลงคะแนนเสียงด้วยตัวเองที่หน่วยเลือกตั้งและไม่มีบัตรเลือกตั้งส�าหรับการลงคะแนนเสียงผ่านทางไปรษณีย์ ผู้ลงคะแนนเสียงอาจยื่นขอรับบัตรเลือกตั้งส�าหรับการลงคะแนนเสียงล่าช้าผ่านทางไปรษณีย์อย่างเป็นลายลักษณ์อักษรได้ ผู้ลงคะแนนเสียงหรือผู้แทนของผู้ลงคะแนนเสียงต้องยื่นใบสมัครนี้ต่อเจ้าหน้าที่เลือกตั้งในมณฑลด้วยตัวเอง บัตรเลือกตั้งส�าหรับการลงคะแนนเสียงล่าช้าผ่านทางไปรษณีย์ดังกล่าวไม่สามารถออกให้หรือส่งคืนผ่านทางไปรษณีย์ได้ และต้องส่งคืนบัตรเลือกตั้งด้วยตัวเองหรือผ่านผู้แทนของผู้ลงคะแนนเสียง

1 ชื่อตัวบรรจง :

ชื่อจริง ชื่อกลางหรืออักษรแรกของชื่อ เดือน/วัน/ปีนามสกุล

2 วันเดือนปีเกิด :

3 ที่อยู่ :

เลขที่และถนน (ไม่รับ ที่อยู่ตู ้ป.ณ.)

เมือง รหัสไปรษณีย์ มณฑล California

5 ค�ำแถลงและก รมอบอ�ำน จ :

ในวันที ่_____________________________ซึ่งเป็นวันเลือกตั้ง ______________________________ ข้าพเจ้าจะไม่สามารถไปที่หน่วย

เลือกตั้งของข้าพเจ้าได้ ข้าพเจ้าขอมอบอ�านาจให ้_______________________________________ เป็นผู้รับบัตรเลือกตั้งของข้าพเจ้า

เดือน/วัน/ปี ขั้นต้น/ทั่วไป/พิเศษ

ผู้แทนที่ได้รับมอบอ�านาจ

และน�าส่งบัตรเลือกตั้งให้แก่ข้าพเจ้า ข้าพเจ้าเข้าใจว่าบัตรเลือกตั้งของข้าพเจ้าไม่สามารถส่งคืนทางไปรษณีย์ได้ ข้าพเจ้าต้องส่งคืนบัตร เลือกตั้งด้ วยตัวเองทีเ่จ้ าหน้ าทีเ่ลือกตั้งในมณฑล หรือทีห่น่วยเลือกตั้งใด ๆ ในมณฑลก่อนเวลา 20:00 น. ในวันเลือกตั้ง

6 ค�ำรับรอง :ข้าพเจ้าขอรับรองภายใต้บทลงโทษในการให้การเท็จตามกฎหมายของรัฐ California ว่า ข้อมูลที่ข้าพเจ้าให้ไว้ในใบสมัครนี้เป็นความ จริงและถูกต้องทุกประการ

ลำยมือชื่อผู้ลงคะแนนเสียง (ไม่เป็นตัวบรรจง) : _______________________________________ วันที่ : _________________________ หากผู้ ลงคะแนนเสียงไม่สามารถลงลายมือชื่อได้ ผู้ ลงคะแนนเสียงอาจท�าเครื่องหมายโดยมีผู้ เป็ นพยานได้

7 พบ ย (ห กเกี่ยวข้อง) :

ลำยมือชื่อพยำน : ____________________________________________________ค�าเตือน : การให้การเท็จเป็นความผิดทางอาญาที่สามารถลงโทษได้โดยการจองจ�าในสถานจองจ�าของรัฐเป็นเวลาสูงสุดสี่ปี (ประมวลกฎหมาย อาญา มาตรา 126)

4 หมำยเลขโทรศัพท์ (ระบุหรือไม่ก็ได)้ :

Đơn Xin Phiếu Bầu Bỏ Phiếu Qua Thư Muộn Tại CaliforniaFOR OFFICIAL USE ONLY

Rev 08/2020

Nếu cử tri không thể bỏ phiếu trực tiếp tại các điểm bỏ phiếu và không có phiếu bầu bỏ phiếu qua thư, cử tri có thể nộp đơn để nhận lá phiếu bầu bỏ phiếu muộn qua thư. Đơn này phải được chính cử tri hoặc đại diện của cử tri nộp trực tiếp cho viên chức bầu cử của quận. Phiếu bầu bỏ phiếu qua thư muộn không được phát hành hoặc gửi lại qua đường bưu điện. Lá phiếu này phải được nộp lại trực tiếp bởi chính cá nhân cử tri hoặc thông qua đại diện của cử tri đó.

1. TÊN VIẾT HOA:

Tên Tên Đệm hoặc Viết Tắt Tên Đệm Tháng/Ngày/NămHọ

2. NGÀY SINH:

3. ĐỊA CHỈ CƯ TRÚ:

Số Nhà và Đường (Không chấp nhận số hòm thư)

Thành Phố Mã Zip Quận California

5. TUYÊN BỐ VÀ ỦY QUYỀN:

Vào ngày ___________________________, ngày diễn ra cuộc bầu cử ____________________________ ,tôi Tháng/Ngày/Năm Bầu Cử Sơ Bộ/Tổng Tuyển Cử/Bầu Cử Đặc Biệt

không thể đến địa điểm bỏ phiếu của tôi. Tôi ủy quyền cho ________________________________ để lấy và giao phiếu bầu của tôi cho tôi. Đại Diện Được Ủy Quyền

Tôi hiểu rằng phiếu bầu của tôi không được nộp lại bằng đường bưu điện. Phiếu bầu phải được nộp lại trực tiếp cho viên chức bầu cử quận hoặc tại bất kỳ địa điểm bỏ phiếu nào trong quận trước 8:00 giờ tối vào Ngày Bầu Cử.

6. CHỨNG NHẬN:Tôi cam đoan rằng những thông tin tôi đã cung cấp trong đơn này là đúng sự thật và chính xác, tôi xin chịu trách nhiệm theo luật của Tiểu Bang California nếu có khai man.

Chữ ký của Cử Tri (Không viết hoa): __________________________________________ Ngày: _________ Có thể đánh dấu chữ thập nếu cử tri không thể ký tên, nhưng phải có người làm chứng.

7. NHÂN CHỨNG (NẾU CÓ):

Chữ ký của Nhân Chứng: ____________________________________________________Cảnh báo: Khai man là trọng tội, và sẽ phải chịu phạt tù lên tới bốn năm tại nhà tù của tiểu bang. (Bộ Luật Hình Sự § 126)

4. SỐ ĐIỆN THOẠI (KHÔNG BẮT BUỘC):



























































CCROV#20178 California Late Vote-by-Mail Ballot Application GE - Final.pdfLate Vote by Mail FINAL_SPL.pdfLate Vote by Mail FINAL_TCH.pdfLate Vote by Mail FINAL_HIN.pdfLate Vote by Mail FINAL_JPN.pdfLate Vote by Mail FINAL_KHM.pdfLate Vote by Mail FINAL_KOR.pdfLate Vote by Mail FINAL_TAG.pdfLate Vote by Mail FINAL_THA.pdfLate Vote by Mail FINAL_VIE.pdf

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ALEX PADILLA | SECRETARY OF STATE | STATE OF CALIFORNIA … · 2 days ago · I understand my ballot may not be returned by mail. It must be returned in person to the county elections