Designated Agent Form - For Voters with Disabilities Who Need Help Picking Up or Returning Mail Voting Materials

Sep 19, 2026

Designated Agent Form for voters with disabilities who need help picking up or returning mail voting materials. The voter completes the top section, authorizing a designated agent to pick up and return application and ballot materials and provide needed voting assistance. The designated agent completes the bottom section, signs, and must carry the completed form when collecting or returning ballots. The form instructs users not to place it in the yellow secrecy envelope and notes penalties for false statements under 18 Pa. C.S. § 4904.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

What is this form for?

Who can use this form?

How do I use this form?

Who can be my designated agent?

How do I get information about voting by mail?

Sections to complete

VOTER section

DESIGNATED AGENT section

Designated Agent Form For voters with disabilities who need help picking up or returning mail voting materials What is this form for? Use this form to choose somebody to help you vote by mail. The person you choose is your designated agent. Your designated agent can: • Pick up and return your application for a mail-in or absentee ballot. • Pick up and return your mail-in or absentee ballot. • Provide other help you need with voting. Who can use this form? You can use this form if you have a disability and need help picking up or returning your ballot or other voting materials. How do I use this form? 1. Complete the top half of this form. 2. Have your designated agent complete the bottom half. 3. It is a good idea to make a copy of the completed form (a photo on a phone is OK) . Keep the copy and give the original form to your designated agent. 4. Your designated agent must have the completed form with them when they pick up or return your ballot or other voting materials. When voting, do not put this form in the yellow secrecy envelope with your completed ballot. Who can be my designated agent? You can choose anyone to be your designated agent except: • Your employer or an agent of your employer. • An officer or agent of your union. It is illegal for anybody to intimidate or coerce you in exercising your right to vote. How do I get information about voting by mail? [Go to vote.pa.gov/mailballot or](Go to vote.pa.gov/mailballot or) call 1-877-868-3772 or your county board of elections. Designated Agent Form For voters with disabilities who need help picking up or returning mail voting materials VOTER, complete this section Enter the address where you are registered to vote. You may wish to keep a copy of this form (a photo on a phone is OK). Give the completed form to your designated agent. Do not put the form in the yellow secrecy envelope with your completed ballot. First name Middle name/initial Last name Address Suffix | City/Town State Zip | | --- | | County
Designated agent’s name | | I have a disability and require assistance with voting by mail. I authorize my designated agent to pick up and return my absentee or mail-in ballot materials. I understand that false statements are punishable under 18 Pa. C.S. § 4904.
If I am unable to sign without help because I have a disability, I have made my mark or somebody has helped me make my mark.
VOTER SIGNATURE | Today's Date DESIGNATED AGENT, complete this section After you complete this form, consider making a copy of itforthe voter (a photo on a phone is OK). You must have the completed form with you when picking up or returning a ballot or other voting materials. Do not put this form in the yellow secrecy envelope that contains the completed ballot. First name Middle name/initial Last name Suffix Address | City/Town
Voter's name | State | Zip | | --- | --- | --- | | | | | I agree to serve as the designated agent for the voter named above. The voter has authorized me to pick up or return their absentee or mail-in ballot materials. I affirm that I have not marked or changed any of the voter's absentee or mail-in ballot materials, unless the voter directed and authorized me to do so. I understand that false statements are punishable under 18 Pa. C.S. § 4904. DESIGNATED AGENT SIGNATURE Today's Date Updated 2024

FAQs

What does a designated agent do under this form?

The designated agent can pick up and return the voter’s mail-in or absentee ballot application, pick up and return the ballot materials, and provide other help the voter needs with voting.

Who is eligible to use this designated agent form?

Voters with disabilities who need help picking up or returning their ballot or other voting materials can use the form.

What are the rules for handling the completed form and ballot envelopes?

Do not put the form in the yellow secrecy envelope with the completed ballot. The agent must have the completed form when picking up or returning ballots or other voting materials.

Sep 19, 2026

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