Form Sbe-703.1 - Annual Absentee Ballot Application Voter With Disability Or Illness Page 2
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1
2INSTRUCTIONS FOR COMPLETING THIS FORM
This Annual Absentee Ballot Application may be used by any registered
P
A: A
V
'
S
ART
BSENTEE
OTER
S
TATEMENT
voter who . . .
- Complete the information at the top.
• is unable to go in person to the polls on the day of election because of a
- Print the name of the city/county in which you are registered
to vote.
disability or illness
- Identify the calendar year for which you are applying.
• and is likely to remain disabled or ill for the remainder of the calendar year.
- Indicate if you will need assistance to mark your absentee
Once your application is accepted, a ballot will be mailed to you for every
ballot for the reasons stated. If the box is checked, an
election in which you are eligible to vote, including general elections
Assistance Form will be sent with the absentee ballot. The
and any special elections. You no longer have to apply for a ballot
form,must be returned with the ballot.
separately for each election. But, you will need to submit a new Annual
- Designate a political party preference only if you wish to vote
Application for each year that you remain eligible to use it and wish to
in the political party's primary, if held.
continue voting absentee. (A blank Annual Application will be mailed to you
- Indicate the address where your absentee ballot is to be sent.
each December to apply for the following year.)
[Note the restrictions on ballot mailing addresses.]
- Read the statement that begins "I declare under felony
If you request primary ballots by designating a political party, and any
penalty of law..."
primary is held for that party's nominations, you will also receive that ballot
- Print your full name, current legal residence (street) address,
automatically.
social security number (last 4 digits are required by law) and
Am I required to designate a political party?
daytime telephone number.
• . No. Virginia law does not require a person to identify a political party
- Sign your name and enter the date signed.
preference (Example: Republican Party or Democratic Party) except when
[Note: A signature based on use of a power of attorney
requesting primary ballots. You may vote in either party's primary, but not in
cannot be accepted on this form or any other form
both primaries held on the same day. If you want to change your primary
relating to voter registration or voting.]
ballot request, simply file a new Annual Application before your primary ballot
has been mailed. If you receive a ballot that you do not wish to vote, or need
P
B: A
'
S
ART
SSISTANT
S
TATEMENT
If the absentee voter is unable to sign his or her name:
a replacement ballot, call your Registrar's office for instructions.
- Write on the voter's signature line: "Applicant Unable to Sign."
What are the special requirements for the Annual Application?
- Print the other information required in Part A as the voter directs.
• . On your FIRST Annual Application only, you must have your physician,
- Print your name and address; sign your name.
accredited religious practitioner, or other state licensed disability
services provider (see definitions below) sign and complete the
P
C: S
D
I
ART
TATEMENT OF
ISABILITY OR
LLNESS
Statement of Disability or Illness (Part C of the application). This
- Required only on first Annual Absentee Ballot Application.
Statement is not required on your SECOND or LATER Annual Applications.
- See instructions at left for information on who is authorized to
sign this Statement.
- Person signing Part C should print his or her name, sign, enter
"Accredited religious practitioner" is a person trained in spiritual healing or
the date signed and their daytime phone number, and check the
other healing arts and accredited by a formal religious order. The signature of a
box to indicate their position.
minister who is not so trained and accredited (ordained or otherwise) is not
acceptable. [§24.2-705, Code of Virginia]
P
D: C
N
A
ART
HANGE OF
AME OR
DDRESS
"Other state licensed disability services provider" is a person, entity, or
To remain a qualified voter, state law requires you to notify the
organization (excluding an agency of the federal government) licensed by the
Registrar of a change in your name or address.
Department of Behavioral Health and Developmental Services. "Provider" includes
[Important Note: If the Annual Application or an absentee ballot is
a hospital, community services board, behavioral health authority, private provider,
returned to the Registrar as “Undeliverable” or if the Registrar
and any other similar or related person, entity, or organization. The signature of
knows that you are no longer a qualified voter, no absentee ballot
the person who is a licensed provider or a representative of the licensed entity or
for any subsequent election will be sent to you until a new Annual
organization is acceptable. [§§ 24.2-703.1 and 37.2-403, Code of Virginia]
Application is filed and accepted.
CHANGE OF NAME OR ADDRESS
ADDITIONAL INFORMATION
PART D
Full Name
If Name Changed, Former Full Name
To vote absentee by mail, your application must be
received by your Registrar by 5:00 PM on the
Tuesday before the election.
New Virginia Residence Address
Apt., Suite or Lot No.
Date Moved
Ballots are available 45 days before most elections
City
State
Zip Code
Your voted ballot must be received by the
Electoral Board before the polls close on election
New Mailing Address (if different from New Virginia Residence Address)
day. (Follow the instructions with your ballot.)
For additional information --
Old Virginia Residence Address
Department of Elections
Toll Free 800-552-9745
TTY 800-260-3466
Signature (required)
Social Security Number (Optional)
SBE-703.1 REV 08/2016
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