I. Prior to any state election, the secretary of state shall prepare the appropriate application forms for absentee ballots worded in substantially the following form. The secretary of state shall insert the names of all parties qualified as set forth in N.H. Rev. Stat. § 652:11 in the list of parties on the application form. The secretary of state shall prepare the application forms in such quantity as he or she deems necessary:
Absence (Excluding Absence Due to Residence Outside the United States), Religious Observance, and Disability:
I hereby declare that (check one):

_____ I am a duly qualified voter who is currently registered to vote in this town/ward.

_____ I am absent from the town/city where I am domiciled and will be until after the next election, or I am unable to register in person due to a disability, and request that the forms necessary for absentee voter registration be sent to me with the absentee ballot.

I will be entitled to vote by absentee ballot because (check one):

_____ I plan to be absent on the day of the election from the city, town, or unincorporated place where I am domiciled.

_____ I am confined in a penal institution for a misdemeanor or while awaiting trial.

_____ I am requesting a ballot for the presidential primary election and I may be absent on the day of the election from the city, town, or unincorporated place where I am domiciled, but the date of the election has not been announced. I understand that I may only make such a request 14 days after the filing period for candidates has closed, and that if I will not be absent on the date of the election I am not eligible to vote by absentee ballot.

_____ I cannot appear in public on election day because of observance of a religious commitment.

_____ I am unable to vote in person due to a disability.

_____ I cannot appear at any time during polling hours at my polling place because of an employment obligation. For the purposes of this application, the term “employment” shall include the care of children and infirm adults, with or without compensation.

For use only on the Monday immediately prior to the election: I cannot appear at my polling place on election day because the National Weather Service has issued a winter storm warning, blizzard warning, or ice storm warning for election day applicable to my city, town, or unincorporated place and either (check one):

_____ I am elderly or infirm or I have a physical disability, and would otherwise vote in person but I have concerns for my safety traveling in the storm.

_____ I anticipate that school, child care, or adult care will be canceled, and would otherwise vote in person but will need to care for children or infirm adults.

Any person who votes or attempts to vote using an absentee ballot who is not entitled to vote by absentee ballot shall be guilty of a misdemeanor. N.H. Rev. Stat. § 657:24.

I am requesting an official absentee ballot for the following election (check one):

_____ Presidential Primary to be held on ____________________

(MM/DD/YYYY)

(The date may appear as blank when the date is not known.)

_____ State Primary to be held on ____________________

(MM/DD/YYYY)

_____ General Election

For primary elections, I am a member of or I am now declaring my affiliation with the (check one):

_____ Republican Party

_____ Democratic Party

_____ (name of any party determined by the secretary of state to have achieved official status under N.H. Rev. Stat. § 652:11)

and am requesting a ballot for that party’s primary.

Please print:

Applicant’s Name:

____________________

(Last) (First) (Middle) (Sr., Jr., II., III)

Applicant’s Voting Domicile (home address):

____________________

(Street Number) (Street Name) (Apt/Unit) (City/Town) (Ward) (Zip Code)

Mail the ballot to me at this address (if different than the home address):

____________________

(Street Number) (Street Name) (Apt/Unit) (City/Town) (Ward) (Zip Code)

Applicant’s Phone Number : ____________________

Applicant’s Email Address : ____________________

Applicant’s Signature: ____________________

Date Signed: ____________________

(MM/DD/YYYY)

I attest that I assisted the applicant in executing this form because he or she has a disability.

Signature ____________________ Print Name ____________________

If your absentee ballot application or affidavit envelope has the printed name and signature of a person who assisted you with voting, your signature will not be compared to your signature on the absentee ballot affidavit to verify your identity. Otherwise, if your signatures do not appear to be made by the same person, your absentee ballot may not be counted.
The applicant must sign this form to receive an absentee ballot. Any person who witnesses and assists a voter with a disability in executing this form shall print and sign his or her name in the space provided on the application form. The moderator will not compare the voter’s signature on the application with the signature on the absentee ballot affidavit when a person assisting the voter has signed the statement on the absentee ballot application or affidavit envelope that assistance was provided.
II. (a) Any person, other than the city or town clerk or the secretary of state, that publishes, mails, or distributes in any manner any written communication that contains a form or post card which a reasonable person would consider as intended to be used by the recipient of the communication to submit a request for an absentee ballot shall identify who is publishing, mailing, or distributing the communication, and attach a copy of the form prepared by the secretary of state pursuant to paragraph I of this section to the communication or include in the communication a complete facsimile of the form prepared by the secretary of state pursuant to paragraph I of this section.
(b) Any person that publishes, mails, or distributes forms as described in subparagraph (a) as part of any communication that is made for the purpose of promoting the success or defeat of a candidate or candidates or measure or measures, as defined in N.H. Rev. Stat. § 664:2, shall be identified in the same manner as political advertising under N.H. Rev. Stat. § 664:14.
(c) Any person that violates this paragraph shall be subject to a civil penalty not to exceed $1,000, to be imposed in the manner set forth in N.H. Rev. Stat. § 659:34, III-V.
III. The federal official post card form shall constitute the form made available by the secretary of state pursuant to N.H. Rev. Stat. § 654:20 for absentee ballot applications by UOCAVA voters.