Fillable Absentee Ballot Application Form - Virginia (Page 3 of 4) in pdf

FOR OFFICE USE ONLY

SBE-701 REV 7/10

Precinct:

District/Sen/House:

Application number:

Reviewed by:

Received:

In person

By mail

By fax

Other

Application accepted:

YES

Reason not accepted:

Date received:

Ballot to be:

Mailed

E-mailed

Voted in person ( On machine :

YES

NO)

Commonwealth of 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/

City of:

Printed Full Name of Absentee Voter (Required)

I am registered to vote in the (Required)

Social Security Number

(last 4 digits required)

I am applying to vote in:

General Election

Democratic Primary

Republican Primary

Check one (Required)

or Special Election

To be held on

PART A

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

Student

Name and address of school attending

Spouse of student

Name and address of school spouse is attending

Business

Name of employer or business

Personal business or vacation

Place of travel (VA county/city or state or country)

I am working and commuting to/from home for 11 or more

Time start AM, time stop PM, name of business or employer,

hours between 6:00 AM and 7:00 PM on Election Day

and workplace address

I am a first responder (member of law enforcement,

Not required

fire fighter, emergency technician, search and rescue)

My disability or illness

Nature of disability or illness

I am primarily and personally responsible for the care of a

Name of family member and nature of disability/illness

disabled/ill family member confined at home

My pregnancy

Not required

Confined, awaiting trial

Place and address of confinement

Confined, convicted of a misdemeanor

Place and address of confinement

An electoral board member, registrar, officer of election,

Not required

or custodian of voting equipment

I have a religious obligation

Religion and nature of obligation

Active Duty Merchant Marine or Armed Forces

Branch of service, Service ID, and rank/grade/rate

Spouse or dependent living with a member of 6A

Branch of service, Service ID, and rank/grade/rate

Temporarily residing outside of US

If your Virginia residence is

no longer available to you ,

provide your last date of residence in Virginia

Temporarily residing outside of US for employment or

Name of business or employer; if your Virginia residence is

spouse or dependent residing with employee

longer available to you, provide your last date of residence in Virginia

Requesting a ballot for presidential and vice-presidential

Not required

electors only (Ballots for other offices/issues will not be sent)

Designated representative of candidate or party inside polls

Must provide name of designating candidate or party

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Absentee Ballot Application Form - Virginia Page 3

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