Application For Voting An Emergency Absent Voter'S Ballot According To The Provision Of Wv Code 3-3-5c Form (Page 2 of 2) in pdf

Application For Voting An Emergency Absent Voter'S Ballot According To The Provision Of Wv Code 3-3-5c Form Page 2

DECLARATION OF EMERGENCY ABSENTEE BALLOT COMMISSIONERS

WV Code §3-3-5c(f)

We,

and

, hereby declare that we are the

duly appointed emergency absent voter's ballot commissioners; that we received this application at

the _________ day of ________________,

_________, and have met the applicant, whose name appears on the

application (page 1), at his/her place of confinement on the_________ day of ________________,

_________, the

date of the election.

We have determined that the applicant has been confined since

because of

__________________________________________________________________________________________________

Reason for Voting Emergency Absentee Ballot

We swear under oath that the ballot was voted by no one other than the absent voter him/herself.

_____________________________________________

Emergency Absentee Ballot Commissioner's signature

___________________

____________________

Date

(Voter or individual assisting voter must complete page 1, the

Application for Voting an Emergency Absent Voter’s Ballot.” )

Please Note: A voter who votes an absentee ballot is not permitted to

vote in person at the polls on Election Day. (WV Code §3-3-9)

A4 Emergency Absentee Ballot Request Application (Page 2)

Issued by the Office of the Secretary of State

Revised 7/16

Application For Voting An Emergency Absent Voter'S Ballot According To The Provision Of Wv Code 3-3-5c Form Page 2