Absentee Ballot Application Form - Virginia Page 4
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4PART 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 and you are located outside of Virginia, or 6C/6D and you are outside of US
PART C
Assistance– I will need assistance in completing my ballot due to a disability, blindness, or inability
to read or write.
PART D
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
M
D
D
Y
Y
Y
Y
/
/
Signature of Registered Voter (Required)
Printed Full Name of Voter (Required)
Date
-
-
-
-
Year of Birth
Daytime Telephone Number
E-mail Address or Fax Number
Social Security Number
(last 4 digits required)
VA
Apt/Unit/Lot/Ste
City/Town
StateZip Code
Residence (Permanent/Currently Registered) Home Address
This address will be used if no other address is checked provided in Part B.
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
State
Zip Code
PART F
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
StateZip Code
Mailing Address if different from New Virginia Residence Address (if Rural Address or if you are a Protected Voter)
M
M
D
D
Y
Y
Y
Y
/
/
Old Virginia Residence (Permanent) Home Address
Date Moved from Old Address
Signature (Required)
SBE-701 REV 7/09
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