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2. I request an absentee ballot be sent to me as provided by Wis Stat 6.86(2)(a), and I certify I am an United States Citizen, age 18 or older and have resided at my legal voting address for at least 18 days. I further certify, I am indefinitely confined due to age, illness, infirmity or disability. I request an absentee ballot be automatically provided for every election until such time as I notify you or until such time as I fail to return an absentee ballot.
4. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. *

   1. I agree. Electronic Signature
6. Signature*
7. Date*
   Date
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9. 1. Receive an email copy of this form.
10. Email address

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11. Submit

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