I certify that I reside at the address specified above, in the stated precinct and county, that I have lived at such address for 30 days or more preceding this election, that I am lawfully entitled to vote in such precinct at said election to be held therein, and that I wish to vote by mail.

I hereby make application for an official ballot or ballots to be voted by me at such election, and I agree that I shall return such ballot or ballots to the official issuing the same prior to the closing of the polls on the date of the election or, if returned by mail, postmarked no later than midnight election day, and received no later than during the period for counting provisional ballots, the last day of which is the 14th day following election day.

I understand that this application is made for an official vote by mail ballot or ballots to be voted by me at the election specified in this application and that I must submit a separate application for an official vote by mail ballot or ballots to be voted by me at any subsequent election.

Under penalties as provided by law pursuant to 10 ILCS 5/29-10, the undersigned certifies that the statements set forth in this application are true and correct.