INSTRUCTIONS FOR APPLICATION FOR BALLOT BY MAIL

1. Name – Print name as you are registered to vote.

2. Residence Address – Give full address as shown on your voter registration certificate. If you have

(Coù loã chaâm kim – Xeù rôøi doïc theo ñöôøng vaïch naøy tröôùc khi göûi qua ñöôøng böu ñieän)
moved but have failed to change your voter registration address with the voter registrar, you are entitled
to vote as long as your registration has not be canceled and you still live in the political subdivision
conducting the election. Indicate your new residence address on the application for ballot by mail. If
you are still qualified to vote, the early voting clerk will mail you a ballot together with a statement of
residence. You are required to return the statement with your ballot. The residence address on the statement of
residence must match the residence address on the application for ballot by mail. If these two addresses do not match,
(Perforated – Tear off on this line before mailing)

your ballot will not be counted.

3. Mailing Address – Balloting materials must be mailed to the residence or mailing address indicated on your voter
registration application. Exceptions include: Voting by reason of 65 years of age or older or disability, the mailing
address may be a facility as indicated on the application or person related to you by 2nd degree by afnity or 3rd
degree by consanguinity if you are temporarily living at that address. Relatives include parent, child, brother, sister,
grandparent, grandchild, great-grandchild, great-grandparent, uncle, aunt, nephew, niece, spouse, spouse’s parent, son-
in-law, daughter-in-law, brother’s spouse, sister’s spouse, spouse’s brother, spouse’s sister, spouse’s grandparent.
Voting by reason of connement in jail, the address to mail your ballot must be either the jail or a relative as stated
above.
You must check on your application which mailing address you are using on the application. If you do not indicate
the type of mailing address your application will be rejected.
4. Type and Date of Election – If you do not indicate type or date of election, you will be sent a ballot only for the next
election.
5. You may return your application by mail, common or contract carrier or fax (if fax is available in the clerk’s ofce).
If you use common or contract carrier, it must be a business for prot carrier and the primary business of which is
transporting or delivering property for compensation. To be eligible to submit an application by fax, you must fax
the application from outside the county. Improper delivery will cause the application to be rejected for a ballot.
6. SIGN YOUR APPLICATION – If you cannot sign, you must have a person witness your mark. If a person helped
you ll out this application, he or she must complete the box for WITNESS and/or ASSISTED section.
In any single election, it is a Class B misdemeanor for any person to sign a ballot application as a witness or assistant
for more than one applicant. A person may sign more than one application as a witness or assistant if the second and
subsequent applications are related to the witness as parent, spouse, child, sibling, or grandparent.
7. Deadline – Your application must be received by the early voting clerk not earlier than the 60th day and not later than
the 7th day before election day. If the 7th day is a weekend or holiday, the deadline is the rst preceding business
day.

CAÙC HÖÔÙNG DAÃN VEÀ ÑÔN XIN LAÙ PHIEÁU BAÀU QUA THÖ
1. Teân – Vieát teân baèng chöõ in nhö khi quyù vò ghi danh boû phieáu.
2. Ñòa Chæ Nôi Cö Nguï – Ghi ñòa chæ ñaày ñuû theo ñuùng nguyeân vaên trong giaáy chöùng nhaän ghi danh boû phieáu cuûa
quyù vò. Neáu quyù vò ñaõ chuyeån nhaø ñi nôi khaùc nhöng chöa thoâng baùo cho nhaân vieân ghi danh cöû tri veà ñòa chæ ghi
danh boû phieáu cuûa mình, quyù vò ñöôïc quyeàn boû phieáu mieãn laø vieäc ghi danh boû phieáu cuûa quyù vò khoâng bò huûy
boû vaø quyù vò vaãn cö nguï trong phaân khu chính trò tieán haønh cuoäc baàu cöû. Cho bieát ñòa chæ nôi cö nguï môùi cuûa quyù
vò trong ñôn xin laù phieáu baàu qua thö. Neáu quyù vò vaãn hoäi ñuû ñieàu kieän boû phieáu, thö kyù phuï traùch boû phieáu sôùm
seõ göûi cho quyù vò moät laù phieáu cuøng vôùi baûn xaùc nhaän veà nôi cö nguï. Quyù vò phaûi göûi laïi baûn xaùc nhaän naøy cuøng
vôùi laù phieáu. Ñòa chæ nôi cö nguï trong baûn xaùc nhaän veà nôi cö nguï phaûi khôùp vôùi ñòa chæ ghi trong ñôn xin laù phieáu
baàu qua thö. Neáu hai ñòa chæ naøy khoâng khôùp nhau, laù phieáu cuûa quyù vò seõ khoâng ñöôïc tính.
3. Ñòa Chæ Böu Tín – Caùc taøi lieäu höôùng daãn boû phieáu phaûi ñöôïc göûi tôùi ñòa chæ nôi cö nguï hoaëc ñòa chæ böu tín ghi
trong ñôn xin ghi danh boû phieáu cuûa quyù vò. Caùc tröôøng hôïp ngoaïi leä bao goàm: Boû phieáu do töø 65 tuoåi trôû leân hoaëc
bò taøn taät, ñòa chæ böu tín coù theå laø moät cô sôû nhö ñöôïc ghi trong ñôn xin hoaëc ngöôøi lieân quan tôùi quyù vò theo moái
quan heä thaân thuoäc ôû caáp ñoä 2 hoaëc quan heä ruoät thòt ôû caáp ñoä 3 neáu quyù vò ñang taïm thôøi cö nguï taïi ñòa chæ ñoù.
Nhöõng ngöôøi thaân bao goàm cha(meï), con caùi, anh chò em, oâng(baø)ø, chaùu noäi/ngoaïi, chaét noäi/ngoaïi, coá noäi/
ngoaïi, chuù (baùc), coâ (dì), chaùu trai, chaùu gaùi, vôï (choàng), cha meï vôï (choàng), con reå, con daâu, vôï (choàng) cuûa
anh (em) trai, vôï (choàng) cuûa chò (em) gaùi, em reå, em daâu, chaùu noäi ngoaïi cuûa vôï (choàng).
Neáu boû phieáu vì lyù do bò giam giöõ trong nhaø tuø, ñòa chæ ñeå göûi laù phieáu cuûa quyù vò phaûi laø nhaø tuø hoaëc ñòa chæ
cuûa moät ngöôøi thaân nhö ghi treân.
Quyù vò phaûi kieåm tra ñôn xin cuûa mình ñeå bieát ñòa chæ böu tín maø quyù vò ñang söû duïng trong ñôn xin. Neáu quyù
vò khoâng cho bieát daïng ñòa chæ böu tín, ñôn xin cuûa quyù vò seõ bò töø choái.
4. Hình Thöùc Baàu Cöû vaø Ngaøy Baàu Cöû – Neáu quyù vò khoâng cho bieát hình thöùc baàu cöû vaø ngaøy baàu cöû, quyù vò seõ chæ
ñöôïc nhaän laù phieáu cho cuoäc baàu cöû tieáp theo.
5. Quyù vò coù theå göûi laïi ñôn xin qua dòch vuï böu tín, qua haõng giao thö thoâng thöôøng hoaëc haõng giao thö theo hôïp
ñoàng hoaëc qua fax (neáu vaên phoøng cuûa thö kyù quaän coù maùy fax). Neáu quyù vò söû duïng dòch vuï böu tín cuûa haõng
giao thö thoâng thöôøng hoaëc theo hôïp ñoàng, ñoù phaûi laø moät haõng giao thö kinh doanh thu lôøi vaø hoaït ñoäng kinh
doanh chính cuûa haõng ñoù laø vaän chuyeån hoaëc giao taøi saûn ñeå laáy thuø lao. Ñeå hoäi ñuû ñieàu kieän noäp ñôn xin qua
fax, quyù vò phaûi fax ñôn xin töø beân ngoaøi quaän. Neáu quyù vò noäp ñôn khoâng hôïp thöùc, ñôn xin cuûa quyù vò seõ bò töø
choái khoâng ñöôïc nhaän laù phieáu.
6. KYÙ TEÂN VAØO ÑÔN XIN CUÛA QUYÙ VÒ – Neáu khoâng theå kyù teân, quyù vò phaûi coù moät ngöôøi laøm chöùng daáu ñieåm
chæ cuûa quyù vò. Neáu coù ngöôøi giuùp quyù vò ñieàn maãu ñôn naøy, ngöôøi ñoù phaûi ñieàn oâ daønh cho muïc ÑÖÔÏC TRÔÏ
GIUÙP vaø/hoaëc NGÖÔØI LAØM CHÖÙNG.
Trong baát kyø moät cuoäc baàu cöû naøo, baát kyø ngöôøi naøo kyù ñôn xin laù phieáu vôùi tö caùch laø ngöôøi laøm chöùng hoaëc
ngöôøi trôï giuùp cho nhieàu hôn moät ñöông ñôn, haønh ñoäng ñoù seõ bò coi laø phaïm khinh toäi Loaïi B. Moät ngöôøi coù theå
kyù nhieàu hôn moät ñôn xin vôùi tö caùch laø ngöôøi laøm chöùng hoaëc trôï giuùp neáu caùc ñöông ñôn trong ñôn xin thöù nhì
Daùn Tem Haïng Nhaát
CLASS POSTAGE

vaø tieáp theo ñoù coù quan heä vôùi ngöôøi laøm chöùng naøy vôùi tö caùch laø cha (meï), vôï (choàng), con caùi, anh chò em,
AFFIX FIRST

hoaëc oâng baø.

7. Thôøi Haïn – Thö kyù phuï traùch boû phieáu sôùm phaûi nhaän ñöôïc ñôn xin cuûa quyù vò trong khoaûng thôøi gian töø 7 tôùi 60
ngaøy tröôùc ngaøy dieãn ra cuoäc baàu cöû. Neáu ngaøy thöù 7 rôi vaøo ngaøy cuoái tuaàn hoaëc ngaøy leã, thôøi haïn seõ laø ngaøy
laøm vieäc ñaàu tieân tröôùc ñoù.
 APPLICATION FOR BALLOT BY MAIL FROM HARRIS COUNTY, TEXAS – PLEASE PRINT OR TYPE
READ INSTRUCTIONS VERY CAREFULLY AND PROVIDE ALL REQUIRED INFORMATION.
(ÑÔN XIN LAÙ PHIEÁU BAÀU QUA THÖ TÖØ QUAÄN HARRIS, TEXAS -XIN VIEÁT BAÈNG CHÖÕ IN HOAËC ÑAÙNH MAÙY

HOUSTON TX 77251-1525
PO BOX 1525
COUNTY CLERK, HARRIS COUNTY
BEVERLY KAUFMAN
XIN ÑOÏC KYÕ CAÙC HÖÔÙNG DAÃN VAØ CUNG CAÁP MOÏI THOÂNG TIN ÑÖÔÏC YEÂU CAÀU.)
NAME (As registered to vote)(TEÂN (Nhö khi ghi danh boû phieáu)) YEAR OF BIRTH (OPTIONAL)
(NAÊM SINH (TUØY CHOÏN)

ADDRESS AS REGISTERED TO VOTE (ÑÒA CHÆ NHÖ KHI GHI DANH BOÛ PHIEÁU)
TYPE AND DATE OF ELECTION
(HÌNH THÖÙC BAÀU CÖÛ VAØ NGAØY BAÀ
´ U
CÖÛ )
NUMBER (SOÁ NHA)Ø STREET (ÑÖÔØNG PHOÁ) Apt.(Caên Hoä)

CITY (THAØNH PHO) STATE (TIEÅU BANG) ZIP (Soá ZIP CODE)
MAIL MY BALLOT TO: (if different from above) (The mailing address must be the voter Check here for ballots for both
registration mailing address of record or address indicated under REASON FOR VOTING.) the main election and runoff if
´
(GÖÛI LAÙ PHIEÁU CUÛA TOÂI TÔÙI: (neáu khaùc vôùi ñòa chæ ôû treân) (Ñòa chæ böu tín phaûi laø ñòa chæ applicable. (Ñaùnh daáu vaøo ñaây
böu tín ghi danh boû phieáu ñöôïc löu trong hoà sô hoaëc ñòa chæ ñöôïc cho bieát döôùi mөc LYÙ DO neáu muoán xin laù phieáu cho cuoäc
BOÛ PHIEÁU). baàu cöû chính vaø cuoäc baàu cöû chung keát
neáu thích hôïp)
PARTY PREFERENCE
PRIMARY ELECTION ONLY
(CHÍNH ÑAÛNG ÖU TIEÂN)
(CHÆ DAØNH CHO CUOÄC BAÀU CÖÛ
CHÍNH)

VOTING PRECINCT NUMBER* VOTER REGISTRATION NUMBER* TELEPHONE NUMBER*

(SOÁ PHAÂN KHU BAÀU CÖÛ*) (SOÁ GHI DANH CÖÛ TRI*) (SOÁ ÑIEÄN THOAÏI *)

Complete the *Optional(*Khoâng baét buoäc)

application and mail to: LANGUAGE PREFERENCE (select type of ballot you wish to receive):
(NGOÂN NGÖÕ MUOÁN SÖÛ DUÏNG (choïn loaïi laù phieáu maø quyù vò muoán ñöôïc nhaän):
† English/Spanish † English/Vietnamese
(Tieáng Anh/Tieáng Vieät)
(Tieáng Anh/Tieáng Taây Ban Nha)
YOU MUST CHECK THE REASON YOU ARE APPLYING FOR A BALLOT BY MAIL.
Harris County Clerk (QUYÙ VÒ PHAÛI ÑAÙNH DAÁU VAØO OÂ CHO BIEÁT LYÙ DO QUYÙ VÒ XIN LAÙ PHIEÁU BAÀU QUA THÖ.)

P.O. Box 1525 † 1. 65 years of age or older. (Treân 65 tuoåi)

† 2. Disability (Tình traïng taøn taät )
Houston, TX You must indicate the type of address where you are having your ballot mailed, if you are having your ballot mailed
to an address other than your address of record. Check one: † a hospital, † a nursing home or long-term care
77251-1525 facility, † a retirement center or † a relative. Indicate the relationship of the relative . SEE
INSTRUCTION #3 FOR CLARIFICATION. (Quyù vò phaûi cho bieát daïng ñòa chæ nôi quyù vò muoán nhaän laù phieáu cuûa
mình qua thö, neáu quyù vò xin göûi laù phieáu cuûa quyù vò qua thö tôùi ñòa chæ khoâng phaûi laø ñòa chæ cuûa quyù vò trong hoà
sô. Ñaùnh daáu vaøo moät oâ: † beänh vieän, † cô sôû ñieàu döôõng hoaëc cô sôû chaêm soùc daøi haïn, † trung taâm höu trí hoaëc
† ngöôøi thaân. Cho bieát moái quan heä cuûa ngöôøi thaân ñoù vôùi quyù vò. XEM HÖÔÙNG
DAÃN SOÁ 3 ÑEÅ ROÕ THEÂM.)
† 3. Connement in jail.(Bò giam giöõ trong nhaø tuø.) Check one. (Ñaùnh daáu vaøo moät oâ) My ballot is being mailed to the
address †of the jail or † a relative. Indicate relationship of relative . SEE INSTRUCTION #3
FOR CLARIFICATION. (Xin göûi laù phieáu cuûa toâi qua ñöôøng böu ñieän tôùi† ñòa chæ cuûa nhaø giam hoaëc †ngöôøi thaân. Cho bieát moái
quan heä cuûa ngöôøi thaân vôùi quyù vò. XEM HÖÔÙNG DAÃN SOÁ 3 ÑEÅ ROÕ THEÂM CHI TIEÁT.)
† 4. Expected absence from county on election day and during clerk’s regular office hours for the
remainder of the early voting period. Application must be submitted from outside county if submitted after early voting
in person has begun. YOUR BALLOT MUST BE MAILED TO AN ADDRESS OUTSIDE THE COUNTY. (Bieát tröôùc
laø seõ vaéng maët trong quaän vaøo ngaøy baàu cöû vaø vaøo caùc giôø laøm vieäc bình thöôøng cuûa vaên phoøng thö kyù trong thôøi gian coøn laïi cuûa thôøi
kyø boû phieáu sôùm. Ñôn xin phaûi ñöôïc noäp töø nôi khaùc ôû beân ngoaøi quaän neáu noäp sau khi thuû tuïc ñích thaân tôùi boû phieáu sôùm ñaõ baét ñaàu.
LAÙ PHIEÁU CUÛA QUYÙ VÒ PHAÛI ÑÖÔÏC GÖÛI QUA ÑÖÔØNG BÖU ÑIEÄN TÔÙI MOÄT ÑÒA CHÆ ÔÛ BEÂN NGOAØI QUAÄN.) If 4 is checked,
give date you can receive mail at the address given . (Neáu ñaùnh daáu vaøo oâ soá 4, xin cho bieát ngaøy maø quyù vò
coù theå nhaän ñöôïc thö taïi ñòa chæ ñaõ ghi.)

I CERTIFY THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TRUE, AND I UNDERSTAND THAT
GIVING FALSE INFORMATION IN THIS APPLICATION IS A CRIME.” (“TOÂI XAÙC NHAÄN RAÈNG CAÙC THOÂNG TIN KHAI
TRONG ÑÔN NAØY LAØ ÑUÙNG, VAØ TOÂI HIEÅU RAÈNG VIEÄC KHAI MAN TRONG ÑÔN XIN NAØY SEÕ BÒ COI LAØ PHAÏM TOÄI”.)

SIGN HERE
(KYÙ TEÂN ÔÛ ÑAÂY ) SIGNATURE OF APPLICANT (CHÖÕ KYÙ CUÛA ÑÖÔNG ÑÔN)
FOR WITNESS and/or ASSISTANT (DAØNH CHO NGÖÔØI LAØM CHÖÙNG vaø/hoaëc NGÖÔØI GIUÙP ÑIEÀN ÑÔN XIN)
Applicant, if unable to sign, shall make mark in presence of witness. If applicant is unable to make mark, the witness
shall check here †. (Neáu khoâng theå kyù teân, ñöông ñôn seõ ñieåm chæ tröôùc söï coù maët cuûa ngöôøi laøm chöùng. Neáu ñöông ñôn khoâng
theå ñieåm chæ, ngöôøi laøm chöùng phaûi ñaùnh daáu vaøo ñaây †.) Failure to complete this information if signature was witnessed
or applicant was assisted in completing the application is a Class A misdemeanor. (Neáu coù ngöôøi laøm chöùng chöõ kyù hoaëc coù
ngöôøi giuùp ñöông ñôn ñieàn ñôn xin nhöng khoâng ñieàn phaàn thoâng tin naøy, vieäc ñoù seõ bò coi laø phaïm khinh toäi Loaïi A.)

Signature of Witness/Assistant Print Full Name of Witness/Assistant

(Chöõ Kyù cuûa Ngöôøi Laøm Chöùng/Ngöôøi Trôï Giuùp Ñieàn Ñôn (Vieát Hoï Teân Ñaày Ñuû cuûa Ngöôøi Laøm Chöùng/Ngöôøi Trôï Giuùp
Xin) BaèngChöõ In)

Residence Address of Witness/Assistant or Title of Witness/Assistant if an Election Ofcial (Ñòa Chæ Nôi Cö Nguï cuûa Ngöôøi Laøm
Chöùng/Ngöôøi Trôï Giuùp hoaëc Chöùc vuï cuûa Ngöôøi Laøm Chöùng/ Ngöôøi Trôï Giuùp neáu laø Vieân Chöùc Phuï Traùch Tuyeån Cöû)
X RELATIONSHIP OF WITNESS/ASSISTANT TO APPLICANT: CHECK ONE: † parent, † grandparent,
† spouse, † child, † sibling, † other, † reside at same address as applicant (MOÁI QUAN HEÄ CUÛA NGÖÔØI LAØM CHÖÙNG/
NGÖÔØI TRÔÏ GIUÙP ÑOÁI VÔÙI ÑÖÔNG ÑÔN: Ñaùnh daáu vaøo moät oâ : † cha (meï), † oâng (baø), † vôï (choàng), † con, † anh chò em,
† moái quan he,ä † khaùc cö nguï taïi cuøng moät ñòa chæ vôùi ñöông ñôn.)