Application For Voting An Emergency Absent Voter'S Ballot According To The Provision Of Wv Code 3-3-5c Form printable pdf download

Precinct #

STATE OF WEST VIRGINIA

Application for Voting an Emergency Absent Voter's Ballot

According to the Provision of WV Code §3-3-5c

Name: __________________________________________________________ Date: ______________________

Residence Address: ___________________________________________________________________________

___________________________________________________________________________

County of Residence: _________________________________________________________________________

Political Party Affiliation: ______________________________________ Date of Birth: _____________________

Reason for Requesting an Emergency Absentee Ballot: (check one box)



I am confined in a hospital or other health care facility within my county of residence or other authorized area

on election day;

Name of Attending Physician: ______________________________________________________________

Physical Address of Place of Confinement: ____________________________________________________

____________________________________________________

Reason for Confinement: __________________________________________________________________



I have resided for less than 30 days in a nursing home within my county of residence and am

unable to vote in person (provided the county commission has adopted a policy extending

emergency absentee voting procedures to such situation).



I am working as a replacement poll worker and I am assigned to a precinct out of my voting district, and the

assignment was made after the period for early voting in person.

Knowing that I can be fined up to $1000 or imprisoned in the county jail for up to one year or both such fine and

imprisonment for knowingly making a false statement or representation herein, as provided in Section three, Article

nine, Chapter three of the Code of West Virginia, I do hereby certify that the statements and declarations contained in

this application are true and correct to the best of my knowledge and belief.

_______________________________________________

Signature/Mark of Voter (if mark, witness must sign this form)

Signature of witness to voter’s mark (if needed)

_______________________________________________

Reason for assistance, if needed

Oath of Voter’s Assistant: I, a person giving assistance to a voter and signing below, hereby swear or affirm that: I will

not in any manner request, persuade or induce the voter I am assisting into voting for someone other than the

candidate of the voter’s choice; and I will not keep or make any memorandum or entry of anything, directly or

indirectly, nor reveal to any person the name of any candidate or issue voted for by the voter or which ticket he or she

voted except when required pursuant to law to give testimony as to the matter in a judicial proceeding.

_______________________________________________

Signature of person assisting voter

A4 Emergency Absentee Ballot Request Application (Page 1)

Issued by the Office of the Secretary of State

Revised 7/16

Application For Voting An Emergency Absent Voter'S Ballot According To The Provision Of Wv Code 3-3-5c Form