Fillable Form A2 Sos - West Virginia Absentee Ballot Application printable pdf download

Precinct # ______

West Virginia Absentee Ballot Application

You must apply separately for each election.

*Applications may be received no earlier than 84 days before an election and no later than 6 days before an election.*

Applying for (select one):

____ Federal, State or County election

____ Municipal Election

Election Type (select one): ____ Primary Election

____ General Election

____Special Election

Choosing your ballot type: If you are registered with the Democratic, Republican or Mountain Party, you may only receive that party’s

primary ballot; voters not registered with any of these parties may select any of the choices below.

For Primary Elections only, choose ballot: (check one)

____Democratic ____Republican ____Mountain ____ Non-Partisan

Current Name and WV Residence Address:

(if this is a new name/address, please complete the information change form on page 2 of this application)

Name:________________________________________________ Date of Birth:____/____/_____ County: ___________________

Street:________________________________________________ City:_____________________________ Zip Code: _________

Mail Ballot To:

(Must be outside county of residence if reason checked is #1, 2, 9 or 10)

Street:__________________________________________________________ Telephone: __________________________________

City: _____________________________ State:______ Zip Code:__________ Country:

_______________________

(If outside the U. S.)

I am applying for an absentee ballot for the following reason:

(Check only ONE box below)

I am not able to vote in person during the early voting period or on Election Day due to:

Personal or business travel.

Attendance at __________________________________________college, university or other place of education or training.

Illness, injury or other medical reason which keeps me confined.

Immobility due to advanced age or a physical disability.

Incarceration or detention in jail or home. I am not under conviction of any felony, of treason or of bribery in an election (including any

period of probation or parole). You must complete the statement on Page 2 of this form if reason #5 is checked.

Employment which because of hours worked and distance from the county seat makes voting in person impossible.

I am a participant in the Address Confidentiality Program (ACP) with the Office of the Secretary of State.

The county absentee voting office and my polling place are inaccessible to me due to my physical disability.

I am required to live temporarily outside my county of residence because of:

Service as an elected or appointed state or federal officer.

10.

Temporary assignment by my employer for a specific period of four years or less.

I do hereby certify the information given above is true to the best of my knowledge, that I reside at the address given, and that I am qualified and

registered to vote in this county. I understand that I must vote in person if I can. I understand that making a false statement on this application

is a crime punishable by a fine up to $1000 and up to one year imprisonment. If I require assistance with my ballot, the reason for the

assistance is stated below and the person who will assist me has signed the oath on this form.

__________________________________________________________

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

Mail, Fax or attach this completed/signed form in an E-mail to your County Clerk’s Office.

Mail, Fax, or E-Mail the completed application to the Monongalia County Clerk's Office at:

Visit

for County Clerk contact information.

Monongalia County Clerk, 243 High St., Courthouse Room 123, Morgantown, WV 26505-5491 phone: (304) 291-7230

fax: (304) 291-7233

E-Mai:

OFFICE USE ONLY: ABS APP RCVD________ BALLOT SENT_________ BALLOT RCVD_________

PG1 FORM A2 SOS