Form A2 Sos - West Virginia Absentee Ballot Application Page 2
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1
2Precinct # ______
Voter’s Change of Name/Address
If you have changed your name or address and have not changed your voter registration, please provide the following
information so that your voter registration record can be updated.
Previous Name and/or WV Residence Address:
Name:________________________________________________ Date of Birth:____/____/_____ County:
___________________
Street:________________________________________________ City:_____________________________ Zip Code:
_________
Statement of Sheriff, Chief of Police or Authorized Deputy
(To be completed for applicants voting absentee because of incarceration or detention)
I, ____________________________________________, hereby declare that the applicant whose signature appears on
this application will be confined in the county or city jail or other detention facility or home confinement on the _______
day of______________, 20_____, the date of the election, and is not under conviction of treason, bribery in an election,
or felony.
______________________________________________
____________________________________________
Name of Detention Facility
Signature
_______________________________________________
____________________________________________
City/County
Title
IMPORTANT REMINDER FOR ALL APPLICANTS
You may NOT vote in person at the polls on Election Day if you have cast an absentee ballot
This application must be RECEIVED by your county clerk (or municipal clerk for city elections*)
NO LATER THAN the 6th day before the election. If you are an ACP participant please send your
application to the Office of the Secretary of State. *
subject to municipal charter provisions
More information on voter registration and elections, including county clerk contact information, may be
found at
.
Published by:
The Office of the Secretary of State
Bldg. 1, Suite 157K
1900 Kanawha Blvd., East
Charleston WV 25305
Phone
304-558-6000
Toll free 866-767-8683
E-mail:
PG2 FORM A2 SOS
V. 7/15
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