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STATEMENT OF A VOTER WITH A DISABILITY, ILLNESS OR PREGNANCYTo be used to request a replacement absentee ballot The completed form must be received by the General Registrar of your county or city
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Obtain the statement of designated representative form.
02
Fill in the date and the name of the company or organization.
03
Provide the contact information of the designated representative.
04
Include the signature of the designated representative.
05
Ensure all information is accurate and complete before submitting the form.

Who needs statement of designated representative?

01
Individuals or entities who are appointing a designated representative to act on their behalf in a specific matter or transaction.
02
Companies or organizations that require representation for legal or administrative purposes.
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A statement of designated representative is a legal document that identifies an individual or entity authorized to act on behalf of another individual or entity in certain matters, particularly in regulatory or administrative contexts.
Individuals or entities that need to appoint a representative to act on their behalf in regulatory matters must file a statement of designated representative.
To fill out the statement, complete the required sections including the names and addresses of both the appointing party and the designated representative, along with any relevant signatures and dates.
The purpose of the statement is to formally designate an individual or entity to act on behalf of another party, ensuring compliance with regulatory requirements and facilitating communication with regulatory bodies.
The statement must report the names and addresses of the appointing party and designated representative, their relationship, and any specific authorities granted to the representative.
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