West Virginia Absentee Ballot Application For Uocava Voters

Precinct # _____

West Virginia Absentee Ballot Application for UOCAVA Voters

If you are a Uniformed Service member, a U.S. citizen residing outside of the country, their spouse or dependent, or a person qualified for

authorized late voter registration, you may use this form to request an absentee ballot. Visit for voting

information and deadlines.

* Applications may be received no earlier than January 1and no later than 6 days before an election, and will remain active for the calendar year *

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 type: (check one)

*Libertarian party will only receive the non-partisan ballot for the

____Democratic ____Republican ____Mountain ____ Non-Partisan

primary election. This party is nominating by convention*

Current Information as registered in West Virginia:

Name: ____________________________________________________________

Date of Birth:____/____/_____

Street (no PO Box):__________________________________________________ City:_______________________________________

Zip Code: __________________ County: _______________________________

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

(check only one)

I am an absent member of Uniformed Services or Merchant Marines on active duty..

I am a U.S. citizen temporarily or permanently residing outside of the U.S.

I am a spouse or dependent of one of the above.

I want to receive my ballot by (check one)  Mail

 E-Mail

 Online

 Fax

Mailing address:

Street or PO Box: ____________________________________________________________

City: __________________________________________

State: _____________________________

Country:(If outside the U. S.) _____________________________ Zip Code: ________________________

Email: ___________________________________________ Fax: _____________________________ Telephone: _____________________________

LATE REGISTRATION AND BALLOT REQUEST FOR RETURNING MILITARY:

I did not return to my county in time to register to vote due to one of the following reasons, and I want to register and request a ballot:

I was absent due to service in the Uniformed Services or Merchant Marines.

I was absent due to employment outside of the U.S. for national security purposes.

I was absent because I am a dependent of one of the above and was residing with him/her.

If you qualify to register to vote after the deadline, you must appear in person at your county clerk’s office to register and apply for an absentee ballot.

You must vote a provisional ballot. Your ballot will be mailed to your West Virginia address. Required affidavits must be submitted with this form.

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 (unless I am registering late). 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 this form.

__________________________________________________________

____________________________________________________________

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

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

_______________________________________________________________

Reason for assistance, if needed

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

Visit

for County Clerk contact information.

OFFICE USE ONLY: ABS APP RCVD________ BALLOT SENT_________ BALLOT RCVD_________

FORM AU1 SOS

V. 7/15

West Virginia Absentee Ballot Application For Uocava Voters - 2015

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