Commonwealth of Virginia ?? 24.2-700 and 24.2-701, Code of Virginia Virginia Absentee Ballot Application Form INSTRUCTIONS INSTRUCTIONS Application for Absentee Ballot Complete all required information in Parts A-D, and Parts E-F, if applicable. Otherwise, your application cannot be processed. TOP OF FORM PART E Complete the information at the top. You must... Be a registered voter in the county/city where you are applying. Identify the election for which you are applying. Assistant: if the absentee voter is unable to sign his/her name due to a disability, blindness, or inability to read or write, the assistant must write on the voter's signature line: "Applicant Unable to Sign." Assistant must complete and sign Part E. Assistant should also ensure that the rest of the application is complete. PART A To vote absentee, select only one code from the list of reason codes. Write in the selected code and include any required information to support the reason (this information is required by state law). Note: First time voters who registered by mail may vote absentee by mail only if the reason code in Part A is 1A, 2A, 2C, 6A, 6B, 6C, 6D, or 7A, or the voter is 65 or older and qualifies under another reason. Reason 7A can only be used if moving to another state less than 30 days before a presidential election. If you are eligible to select reason 7A, you must complete Part F of the application indicating your new address in another state. PART B Print the address where your absentee ballot is to be sent, if voting by mail. The ballot can only be sent to: The address where the voter will be while out of their county/city; or The address where the voter is temporarily confined due to an illness or disability; or The address where the voter is currently registered or newly registered; or The address where the voter is confined awaiting trial or having been convicted of a misdemeanor. A military or overseas voter (reasons 6A, 6B, 6C, or 6D) may ask to receive their ballot by e-mail or fax. The ballot cannot be sent "in care of" any other person. PART C Indicate if assistance from another person will be needed to vote the ballot due to the voter's disability, blindness or inability to read or write. If Yes is checked, an Assistance Form will be sent with the absentee ballot. The form, to be returned with the ballot, provides a legal safeguard for the voter and the assistant. PART D Absentee Voter: Read the Statement in Part D. Then print your full name, current residence (permanent) home address, social security number (last 4 digits required) and a daytime telephone number. Sign your name. If applying in person, the application must be signed in the presence of a registrar or a member of the electoral board. Note: A signature under a power of attorney cannot be accepted. (Also see Part E.) Protected voters may list a Virginia post office box address. Contact your voter registration office for details. PART F To remain a qualified voter, state law requires you to notify the General Registrar of a change in your name or address. Complete Part F and sign your name. ATTENTION VOTERS Apply early! You can apply to vote absentee as early as one ATTENTION VOTERS apply in person at your city year before the election. You can Apply early! You can apply to vote absentee as early as one or county voter registration office or by sending at your city year before the election. You can apply in persona completed application by registration scanned copy. If you register to or county votermail, fax, or aoffice or by sending a completed application by mail, must wait five days before you can vote in vote in person, you fax, or a scanned copy. Ballots are available 45 days before Primary andyou. Ballots are person or have your ballot mailed to General elections and most Specialdays before Primary and General elections and available 45 Elections. most Special Elections. If applying and voting by mail, allow enough time for your If applying to be processed and your ballot time for your application and voting by mail, allow enoughmailed to you. The deadline forto be processed and your ballot mailed to PM the application applying to vote absentee by mail is 5:00 you. Tuesday before the election. vote absentee by mail is 5:00by The deadline for applying to All ballots must be received PM the Electoral before by 7:00 PM on election day. Ifbe received the Tuesday Board the election. All ballots must returning the ballot to the Electoral Board in person, only the voter may by the Electoral Board by 7:00 PM on election day. If return it. returning the ballot to the Electoral Board in person, only the voter may return it. The deadline for applying and casting your ballot in-person at your deadline for applying and casting your ballot in-person The local voter registration office is the Saturday before the election. at your local voter registration office is the Saturday before the election. Visit the State Board of Elections website, Visit the State Board of Elections website, http://www.sbe.virginia.gov for: http://www.sbe.virginia.gov for: Contact information for your local voter registration Contact information for your local voter registration office office Information about absentee voting Information about absentee voting The status of your absentee application The status of your absentee application (under (under Voter Information, Registration Status). Voter Information, Registration Status). Toll Free 800 552 9745 (TTY 800 260 3466). Toll Free 800 552 9745 (TTY 800 260 3466). ATTENTION MILITARY & OVERSEAS VOTERS ATTENTION MILITARY & OVERSEAS VOTERS You are encouraged to use the Federal Post Card Application You are encouraged to use the Federal Post Card (FPCA) which also serves as a voter registration application. Application (FPCA) which also serves as http://www.fvap.gov. To obtain the FPCA and information, visit a voter registration application. To obtain Absentee Ballot Application form will Submitting this Virginiathe FPCA and information, visit http://www.fvap.gov. Submitting this discontinue any pending be interpreted as a request by you to Virginia Absentee Ballot FPCA. You can submit a interpreted as a request by you to Application form will be new FPCA is you are eligible. discontinue any pending FPCA. You can submit a new FPCA if you are eligible. Privacy Act Notice: This form collects personal information, including your social security number, for identification and to prevent fraud. Your application will be denied if you fail to provide the last four digits of your social security number or any other information required to determine your qualification to vote absentee. Federal law (the Privacy Act) and state law (Va. Code ? 24.2-701 and the Government Data Collection and Dissemination Practices Act) authorize collecting this information and restrict its use to official purposes only. 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. SBE-701 Rev 8.12 List of Voter Registration Offices (General Registrar) as of 4/19/2012 Accomack County PO Box 97 Accomac, VA 23301-0097 (757) 787 ? 2935 Albemarle County PMB 404, 536 Pantops Center Charlottesville, VA 22911 (434) 972 ? 4173 Alexandria City 132 North Royal St, Ste. 100 Alexandria, VA 22314-3283 (703) 746 ? 4050 Alleghany County 110 Rosedale Ave, Ste. D Covington, VA 24426-1294 (540) 965 ? 1690 Amelia County PO Box 481 Amelia, VA 23002-0481 (804) 561 ? 3460 Amherst County PO Box 550 Amherst, VA 24521-0550 (434) 946 ? 9315 Appomatox County PO Box 8 Appomatox, VA 24522-0008 (434) 352 ? 5302 Arlington County 2100 Clarendon Blvd, Ste. 320 Arlington, VA 22201-5400 (703) 228 ? 3456 Augusta County PO Box 590 Verona, VA 24482-0590 (540) 245 ? 5656 Bath County PO Box 157 Warm Springs, VA 24484-0157 (540) 839 ? 7266 Bedford County County Admin Building 122 East Main St, Ste. 204 Bedford, VA 24523-2000 (540) 586 ? 7649 Bedford City 215 East Main St Bedford, VA 24523-2012 (540) 587 ? 6007 Bland County PO Box 535 Bland, VA 24315-0535 (276) 688 ? 4441 Botetourt County PO Box 62 Fincastle, VA 24090-0062 (540) 473 ? 8235 Bristol City 300 Lee St Bristol, VA 24201-4327 (276) 645 ? 7318 Brunswick County 100 Tobacco St, Rm. 103 Lawrenceville, VA 23868-1823 (434) 848 ? 4414 Buchanan County PO Box 975 Grundy, VA 24614-0975 (276) 935 ? 6534 Buckingham County PO Box 222 Buckingham, VA 23921-0222 (434) 969 ? 4304 Buena Vista City 2039 Sycamore Ave Buena Vista, VA 24416-3133 (540) 261 ? 8605 Campbell County PO Box 103 Rustburg, VA 24588-0103 (434) 332 ? 9579 Caroline County PO Box 304 Bowling Green, VA 22427-0304 (804) 633 ? 9083 Carroll County Governmental Center 605-3 Pine St, B 110 Hillsville, VA 24343-1404 (276) 730 ? 3035 Charles City County PO Box 146 Charles City, VA 23030-0146 (804) 652 ? 4606 Charlotte County PO Box 118 Charlotte CH, VA 23923-0118 (434) 542 ? 5856 Charlottesville City PO Box 911 Charlottesville, VA 22902-0911 (434) 970 ? 3250 Chesapeake City 411 Cedar Rd Chesapeake, VA 23322-5566 (757) 277 ? 9797 Chesterfield County PO Box 1690 Chesterfield, VA 23832-1690 (804) 748 ? 1471 Clarke County PO Box 555 Berryville, VA 22611-0555 (540) 955 ? 5168 Colonial Heights City PO Box 3401 Colonial Heights, VA 23834-9001 (804) 520 ? 9277 Covington City 515 E. Pine St Covington, VA 24426-1534 (540) 965 ? 6380 Craig County PO Box 8 New Castle, VA 24127-0008 (540) 864 ? 6190 Culpeper County 151 North Main St, Ste. 301 Culpeper, VA 22701 (540) 825 ? 0652 Cumberland County PO Box 125 Cumberland, VA 23040-0008 (804) 492 ? 4504 Danville City 515 Main St Danville, VA 24541-1317 (434) 799 ? 6560 Dickenson County PO Box 1306 Clintwood, VA 24228-1306 (276) 926 ? 1620 Dinwiddie County PO Box 365 Dinwiddie, VA 23841-0365 (804) 469 ? 4500 option 7 Emporia City PO Box 1092 Emporia, VA 23847-1092 (434) 634 ? 9533 Essex County PO Box 1561 Tappahannock, VA 22560-1561 (804) 443 ? 4611 Fairfax County 12000 Govt Ctr Pkwy, Ste. 323 Fairfax, VA 22035-0081 (703) 222 ? 0776 Fairfax City Sisson House 10455 Armstrong St Fairfax, VA 22030-3640 (703) 385 ? 7890 Falls Church City 300 Park Ave, Rm 101E Falls Church, VA 22046-3332 (703) 248 ? 5085 Fauquier County 32 Waterloo St, Ste. 207 Warrenton, VA 20186-3238 (540) 422 ? 8290 Floyd County 100 East Main St, Rm. 302 Floyd, VA 24091-2101 (540) 745 ? 9350 Fluvanna County PO Box 44 Palmyra, VA 22963-0044 (434) 589 ? 3593 Franklin County 1255 Franklin St, Ste. 106 Rocky Mount, VA 24151-1289 (540) 483 ? 3025 Franklin City PO Box 42 Franklin, VA 23851-0042 (757) 562 ? 8545 Frederick County 107 North Kent St, Ste. 102 Winchester, VA 22601-5039 (540) 665 ? 5660 Fredericksburg City Executive Plaza 601 Caroline St, Ste. 500-A Fredericksburg, VA 22401 (540) 372 ? 1030 Galax City PO Box 1045 Galax, VA 24333-1045 (276) 236 ? 7509 Giles County 201 N. Main St, Ste. 1 Pearisburg, VA 24134-1611 (540) 921 ? 2802 Gloucester County PO Box 208 Gloucester, VA 23061-0208 (804) 693 ? 3659 Goochland County PO Box 1013 Goochland, VA 23063-1013 (804) 556 ? 5803 Grayson County PO Box 449 Independence, VA 24348-0449 (276) 773 ? 2842 Greene County PO Box 341 Stanardsville, VA 22973-0341 (434) 985 ? 5213 Greensville County PO Box 1092 Emporia, VA 23847-1092 (434) 348 ? 4228 Halifax County PO Box 400 Halifax, VA 24558-0400 (434) 476 ? 3322 Hampton City 1919 Commerce Dr, Ste. 280 Hampton, VA 23666 (757) 727 ? 6218 Hanover County PO Box 419 Hanover, VA 23069-0419 (804) 365 ? 6080 Harrisonburg City PO Box 20031 Harrisonburg, VA 22801-7531 (540) 432 ? 7707 Henrico County PO Box 90775 Henrico, VA 23273-0775 (804) 501 ? 4347 Henry County PO Box 7 Collinsville, VA 24078-0007 (276) 638 ? 5108 Highland County PO Box 386 Monterey, VA 24465-0386 (540) 468 ? 2013 Hopewell City 309 North 2nd Ave Hopewell, VA 23860-2704 (804) 541 ? 2232 Isle of Wight County PO Box 77 Isle of Wight, VA 23397-0077 (757) 365 ? 6230 James City County PO Box 3567 Williamsburg, VA 23187-3567 (757) 253 ? 6868 King & Queen County PO Box 56 King & Queen CH, VA 23085-0056 (804) 785 ? 5980 King George County PO Box 1359 King George, VA 22485-1359 (540) 775 ? 9186 King William County PO Box 173 King William, VA 23086-0173 (804) 769 ? 4952 Lancaster County PO Box 159 Lancaster, VA 22503-0159 (804) 462 ? 5277 Lee County PO Box 363 Jonesville, VA 24263-0363 (276) 346 ? 7780 Lexington City PO Box 922 Lexington, VA 24450-0922 (540) 462 ? 3706 Loudoun County 750 Miller Drive, SE, Ste. C Leesburg, VA 20175-8916 (703) 777 ? 0380 Louisa County PO Box 220 Louisa, VA 23093-0220 (540) 967 ? 3427 Lunenburg County 160 Courthouse Sq Lunenburg, VA 23952-9999 (434) 696 ? 3071 Lynchburg City 3236 Odd Fellows Rd Lynchburg, VA 24501 (434) 847 ? 1609 Madison County PO Box 267 Madison, VA 22727-0267 (540) 948 ? 6533 Manassas City 9025 Center St Manassas, VA 20110-5403 (703) 257 ? 8230 Manassas Park City City Hall. 1 Park Center Ct Manassas Park, VA 20111-2395 (703) 335 ? 8806 Martinsville City PO Box 1323 Martinsville, VA 24114-1323 (276) 403 ? 5122 Mathews County PO Box 328 Mathews, VA 23109-0328 (804) 725 ? 3200 Mecklenburg County PO Box 436 Boydton, VA 23917-0436 (434) 738 ? 6191 Middlesex County PO Box 358 Saluda, VA 23149-0358 (804) 758 ? 4420 Montgomery County 755 Roanoke St, Ste. 1F Christiansburg, VA 24073-3175 (540) 382 ? 5741 Nelson County PO Box 292 Lovingston, VA 22949-0292 (434) 263 ? 4068 New Kent County PO Box 128 New Kent, VA 23124-0128 (804) 966 ? 9699 Newport News City 2400 Washington Ave Newport News, VA 23607-4305 (757) 926 ? 8683 Norfolk City PO Box 1531 Norfolk, VA 23501-1531 (757) 664 ? 4353 Northampton County PO Box 510 Eastville, VA 23347-0510 (757) 678 ? 0480 Northumberland County PO Box 84 Heathsville, VA 22473-0084 (804) 580 ? 4655 Norton City PO Box 225 Norton, VA 24273-0225 (276) 679 ? 1162 Nottoway County PO Box 24 Nottoway, VA 23955-0024 (434) 645 ? 8148 Orange County 146 Madison Rd, Ste. 204 Orange, VA 22960-1449 (540) 672 ? 5262 Page County 551 Mechanic St Luray, VA 22835-1820 (540) 743 ? 3986 Patrick County PO Box 635 Stuart, VA 24171-0635 (276) 694 ? 7206 Petersburg City PO Box 1031 Petersburg, VA 23804-1031 (804) 733 ? 8071 Pittsylvania County 110 Old Chatham Elementary Ln Chatham, VA 24531 (434) 432 ? 7971 Poquoson City 500 City Hall Ave, Rm. 139 Poquoson, VA 23662-1996 (757) 868 ? 3070 Portsmouth City 801 Crawford St,1st Fl Portsmouth, VA 23704-3822 (757) 393 ? 8644 Powhatan County 3834 Old Buckingham Rd, Ste. G Powhatan, VA 23139-7051 (804) 598 ? 5604 Prince Edward County PO Box J Farmville, VA 23901 (434) 392 ? 4767 Prince George County PO Box 34 Prince George, VA 23875-0034 (804) 722 ? 8748 Prince William County 9250 Lee Ave, Suite 1 Manassas, VA 20110-5554 (703) 792 ? 6470 Pulaski County 52 West Main St, Ste. 300 Pulaski, VA 24301-5045 (540) 980 ? 2111 Radford City 619 2nd St Radford, VA 24141 (540) 731 ? 3639 Rappahannock County PO Box 236 Washington, VA 22747-0236 (540) 675 ? 5380 Richmond County PO Box 1000 Warsaw, VA 22572-1000 (804) 333 ? 4772 Richmond City PO Box 61037 Richmond, VA 23261-1037 (804) 646 ? 5950 Roanoke County PO Box 20884 Roanoke, VA 24018-0089 (540) 772 ? 7500 Roanoke City PO Box 1095 Roanoke, VA 24005-1095 (540) 853 ? 2281 Rockbridge County 150 S. Main St Lexington, VA 24450 (540) 463 ? 7203 Rockingham County 20 E. Gay St Harrisonburg, VA 22802-4108 (540) 564 ? 3055 Russell County PO Box 383 Lebanon, VA 24266-0383 (276) 889 ? 8006 Salem City PO Box 203 Salem, VA 24153-0203 (540) 375 ? 3034 Scott County PO Box 1892 Gate City, VA 24251-3417 (276) 386 ? 3843 Shenandoah County 600 N. Main St, Ste. 103 Woodstock, VA 22664 (540) 459 ? 6195 Smyth County 121 Bagley Cir, Ste. 108 Marion, VA 24354 (276) 783 ? 4511 Southampton County PO Box 666 Courtland, VA 23837-0666 (757) 653 ? 9280 Spotsylvania County PO Box 133 Spotsylvania, VA 22553-0133 (540) 507 ? 7380 Stafford County PO Box 301 Stafford, VA 22555-0301 (540) 658 ? 4000 Staunton City PO Box 58 Staunton, VA 24402-0058 (540) 332 ? 3840 Suffolk City PO Box 1966 Suffolk, VA 23439-1966 (757) 514 ? 7750 Surry County PO Box 264 Surry, VA 23883-0264 (757) 294 ? 5213 Sussex County PO Box 1302 Sussex, VA 23884-0302 (434) 246 ? 1047 Tazewell County PO Box 201 Tazewell, VA 24651-0201 (276) 988 ? 1305 Virginia Beach City PO Box 6247 Virginia Beach, VA 23456-0247 (757) 385 ? 8683 Warren County 220 North Commerce Ave, Ste. 700 Front Royal, VA 22630 (540) 635 ? 4327 Washington County 25552 Lee Hwy, Ste. 1 Abingdon, VA 24211-7466 (276) 676 ? 6227 Waynesboro City 250 S. Wayne Ave, Ste 205 Waynesboro, VA 22980 (540) 942 ? 6620 Westmoreland County PO Box 354 Montross, VA 22520-0354 (804) 493 ? 8898 Williamsburg City PO Box 3538 Williamsburg, VA 23187-3538 (757) 220 ? 6157 Winchester City 107-A N. East Lane Winchester, VA 22601-5072 (540) 545 ? 7910 Wise County PO Box 309 Wise, VA 24293-0309 (276) 328 ? 8331 Wythe County 245 South Fourth St, Ste. 101 Wytheville, VA 24382-2598 (276) 223 ? 6038 York County PO Box 451 Yorktown, VA 23690-0451 (757) 890 ? 3440 SBE-701 Rev. 2012.7.1 FOR OFFICE USE ONLY Precinct: Received: Application number: District/Sen/House: In person Date received: M M / By mail D D / Y By fax Y Y Other Y Application accepted: Ballot to be: Mailed Reviewed by: YES NO E-mailed Reason not accepted: Voted in person (On machine: YES NO) Virginia Absentee Ballot Application Submit a separate form for each person and for each election. Must Complete Parts A through D (and E/F if applicable). County/ I am registered to vote in the (Required) Printed Full Name of Absentee Voter (Required) I am applying to vote in: General Election Check one (Required) or Special Election PART A - City of: Democratic Primary Republican Primary - Social Security Number (last 4 digits required) M M D D / / To be held on Y Y Y Y Under Virginia law a registered voter may qualify to vote absentee by completing one of the following statements. Note: First time voters who registered by mail may be ineligible to apply to vote absentee by mail. See Instructions page. I will be absent on Election Day from the county/city in which I am registered to vote (reasons 1A, 1B, 1C, 1D, 6A, 6B, 6C or 6D), or will be unable to go to the polls on Election Day (other reasons except 7A) because: Required Code Supporting Information (Required for all codes except 1F, 2C, 4A or 7A) Code Reason Supporting Information Required 1A Student Name and address of school attending 1B Spouse of student Name and address of school spouse is attending 1C Business Name of employer or business 1D Personal business or vacation Place of travel (VA county/city or state or country) 1E I am working and commuting to/from home for 11 or more hours between 6:00 AM and 7:00 PM on Election Day Time start AM, time stop PM, name of business or employer, and workplace address 1F I am a first responder (member of law enforcement, fire fighter, emergency technician, search and rescue) Not required 2A My disability or illness Nature of disability or illness 2B I am primarily and personally responsible for the care of a disabled/ill family member confined at home Name of family member and nature of disability/illness 2C My pregnancy Not required 3A Confined, awaiting trial Place and address of confinement 3B Confined, convicted of a misdemeanor Place and address of confinement 4A An electoral board member, registrar, officer of election, or custodian of voting equipment Not required 5A I have a religious obligation Religion and nature of obligation 6A Active Duty Merchant Marine or Armed Forces Branch of service, Service ID, and rank/grade/rate 6B Spouse or dependent living with a member of 6A Branch of service, Service ID, and rank/grade/rate 6C Temporarily residing outside of US If your Virginia residence is no longer available to you, provide your last date of residence in Virginia 6D Temporarily residing outside of US for employment or spouse or dependent residing with employee Name of business or employer; if your Virginia residence is no longer available to you, provide your last date of residence in Virginia Not required 7A Requesting a ballot for presidential and vice-presidential electors only (Ballots for other offices/issues will not be sent) 8A Designated representative of candidate or party inside polls Must provide name of designating candidate or party OVER SBE-701 Rev. 2012.7.1 PART B Send my ballot to: the address where I am currently registered, provided in Part D. my new Virginia residence (permanent) home address, provided in Part F. the following address. (See the instructions page for addresses allowed.) Street Address City/Town State Zip Code Email/Fax only if reason in Part A is 6A, 6B, 6C or 6D. PART C PART D Assistance- I will need assistance in completing my ballot due to a disability, blindness, or inability to read or write. Absentee Voter's Statement I declare under felony penalty that, to the best of my knowledge, the facts contained in this application are true and correct, and that I have not, and will not vote in this election at any other place in Virginia or in any other state. Knowingly giving any untrue information in this document is a felony under Virginia law. The maximum penalty is a fine of $2500 and/or confinement for up to ten years. M Signature of Registered Voter (Required) - Social Security Number (last 4 digits required) Year of Birth / Date Printed Full Name of Voter (Required) - M D D / Y Y Y Y - Daytime Telephone Number E-mail Address or Fax Number VA Residence (Permanent/Currently Registered) Home Address Apt/Unit/Lot/Ste City/Town This address will be used if no other address is checked or provided in Part B. State Zip Code If applicant is unable to sign due to a physical disability, write the name/address of person who assisted in Part E (required). Check here if submitting a change of name or address in Part F. PART E Assistant's Statement (Required only if voter received assistance in completing this application due to a disability, blindness, or inability to read or write.) I declare, under felony penalty of law, that... ? I have written on Applicant's Signature line in Part D: "Applicant Unable to Sign." ? I have signed and provided requested information below. Signature of Assistant Printed Full Name of Assistant Address of Assistant City/Town PART F State Zip Code Change of Name or Address Full Name If Name Changed, Former Full Name VA New Virginia Residence (Permanent) Home Address Apt/Unit/Lot/Ste City/Town State Zip Code Mailing Address if different from New Virginia Residence Address (if Rural Address or if you are a Protected Voter) M Old Virginia Residence (Permanent) Home Address Signature (Required) M D D Y Y Y Y / / Date Moved from Old Address SBE-701 Rev. 2012.7.1