REQUERIMENTO DE JUSTIFICATIVA ELEITORAL

EXCELENTSSIMO(A) SENHOR(A) JUIZ(A) DA ________ ZONA ELEITORAL

MUNICPIO/UF: __________________________________________ / ___

Eu (nome completo em letra de forma), _____________________________________________________________

_______________________________________________________________________________________________,
portador(a) do Ttulo Eleitoral n _______________________, da Zona n __________, Seo n ___________,
residente e domiciliado(a) na(o) _____________________________________________________________________
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CEP/ZIPCODE ______________________, Cidade ____________________________________________, Estado
__________________________,

Pas

________________________________,

telefone

(DDD

ou

DDI/n)

_______________________, filho(a) de ____________________________________________________________ e

de

____________________________________________________________________,

nascido(a)

em

____/____/_______, (DD/MM/AAAA), venho apresentar a Vossa Excelncia, nos termos do art. 7 da Lei
n. 4.737, de 1965, c.c. art. 80, caput e 1, da Res.-TSE n 21.538, de 2003, JUSTIFICATIVA DE AUSNCIA DE
VOTO no(s) turno(s) de votao realizado(s) no(s) ano(s) abaixo especificado(s), pelo(s) motivo(s) que passo a relatar:

TURNO

VOTAO

ANO (especificar)

eleio

_____________________________________________________________________

plebiscito

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referendo

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Termos em que
Peo deferimento

_______________________________________________
(local e data)
______________________________________________
(assinatura do(a) eleitor(a))
Documentos comprobatrios anexados:
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