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COMMONWEALTH OF VIRGINIA

‘‘

FOR REGISTRAR USE ONLY

ANNUAL ABSENTEE BALLOT APPLICATION

PCT

APP

DATE THIS APP

RECEIVED

VOTER WITH DISABILITY OR ILLNESS

DATE STATEMENT FILED BY PHYSICIAN

PROVIDER

PRACTIONER

§§ 24.2-700, 24.2-701, 24.2-703.1 and 24.2-704, Code of Virginia

REGISTERED

YES

REVIEWED BY

FOR COMPLETE INSTRUCTIONS AND DEADLINES SEE REVERSE

SIDE_

ACCEPTED

YES

REASON DENIED

ABSENTEE VOTER'S STATEMENT --

PART A

I am registered to vote in the

County/ City of:

•

I am unable to go in person to the polls on election day because of my disability or illness and am likely to remain disabled or ill for

•

the rest of the calendar year.

• I am applying to receive an absentee ballot for each election in which I am eligible to vote in calendar year 20

• I also request ballots for any primary held for nominations of the [check no more than one; if neither party is checked, primary ballots will

not be sent]:

Democratic Party

Republican Party

I WILL NEED ASSISTANCE IN MARKING MY BALLOT due a disability, blindness, or inability to read or write (or need the

ballot translated into another language). [If you check this box, the required form will be sent with your ballot.]

[Check one]:

I am submitting my FIRST Annual Application for an Absentee Ballot and the Statement of Disability or Illness (below) has been

signed by my physician or other state licensed disability services provider or accredited religious practitioner.

This is NOT my first Annual Application. [Part C. Statement of Disability or Illness is not needed for second or later Annual

Applications.]

Send the ballot to me at [check one]:

NOTE: When you return from this temporary address, you must let the Registrar know (by

phone or by filing a revised Annual Application) so that future ballots will be sent to your

The address listed below where I am currently registered. [This

residence. If your ballot is returned as "undeliverable," no additional ballots can be sent

address will be used if no other address is checked or provided.]

until a new application is filed and accepted.

My new Virginia residence address provided on the reverse.

Street Address

The address printed to the right, where I am temporarily

confined due to illness or disability, or where I will be while

outside of my county/city.

City/Town

State

Zip

Note: Ballot cannot be sent "in care of" anyone else. Ballot may only be

sent to the addresses described above.

I declare under felony penalty of law, that, to the best of my

ASSISTANT'S STATEMENT

PART B

[ONLY required if applicant unable to sign due to disability or inability to read or

knowledge, the facts contained in this application are true and

write. Assistance box above should also be checked.]

correct, and that I have not and will not vote in the elections for

I declare, under penalty of law, that:

which I am applying at any other time or place in Virginia or in

• I have written on applicant's signature line:

any other state.

"Applicant Unable to Sign"

Full Name of Absentee Voter

• I have signed and provided requested information below

Full Name of Assistant

Legal Virginia Residence Address

City/Town

Zip

Residence Address of Assistant

Social Security Number [Last 4 digits required]

Area Code

Daytime Phone

City/Town

Zip

Signature of Applicant

Signature of Assistant

Date

STATEMENT OF DISABILITY OR ILLNESS [

This statement is ONLY required for the applicant's FIRST Annual Application.]

PART C

]

[

PRINT NAME

, certify that the above named applicant is unable to go in person

to the polls on election day because of a disability or illness and is likely to remain so disabled or ill for the remainder of the calendar year.

SIGNATURE

DATE

AYTIME

HONE

[

MUST CHECK ONE

I AM THE APPLICANT

LICENSED PHYSICIAN

LICENSED DISABILITY SERVICES PROVIDER

ACCREDITED RELIGIOUS PRACTITIONER

[

IF YOU HAVE QUESTIONS ABOUT THE QUALIFICATIONS FOR USING THIS APPLICATION OR SIGNING THIS STATEMENT

SEE INSTRUCTIONS ON REVERSE

WARNING: INTENTIONALLY MAKING A MATERIALLY FALSE STATEMENT ON THIS FORM CONSTITUTES THE CRIME OF ELECTION FRAUD,

WHICH IS PUNISHABLE UNDER VIRGINIA LAW AS A FELONY. VIOLATORS MAY BE SENTENCED TO UP TO 10 YEARS IN PRISON, OR UP TO 12

MONTHS IN JAIL AND/OR FINED UP TO $2,500. YOU ALSO LOSE YOUR RIGHT TO VOTE.

Privacy Act Notice: This form requires the last four digits of your social security number for identification and to prevent fraud. Your application will be

denied if you fail to provide this or any other information necessary to determine your qualification to vote. Federal law (the Privacy Act and Help America

Vote Act) and state law (the Virginia Constitution, Article II, § 2, Title 24.2 of the Code of Virginia and the Government Data Collection and Dissemination

Practices Act) authorize collecting this information and restrict its use to official purposes only.

SBE-703.1 REV 08/2016