Form Sbe-701 - Virginia Absentee Ballot Application Page 3
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1
2
3
4Page 3
!
Upon completion of the form, return this page only to the address on page 2 for the city/county where you are applying.
Virginia Absentee Ballot Application Form
*
Unless otherwise indicated, all items on this form are required. Please print clearly. Instructions on page 4.
First Name
Last Name
1
Your Name
Social Security #
& SSN
N
N
N
N
N
N
N
N
N
Suffix
-
-
Middle Name
(Last 4 digits required)
2
I am applying to vote in:
General or Special Election
Democratic Primary
Republican Primary
Election
I am registered to vote in the
M
M
D
D
Y
Y
/
/
Date of Election
County
City
of
*
!
Your application will be denied if a qualifying reason and
Instructions on reason
3
Reason for
required information are not provided.
codes are on page 4
Absentee Ballot
Supporting Info
N
N
Reason Code
(if required)
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
4
Telephone
Birth Year
-
-
More Info
(Optional)
Email/Fax
Residence
APT/Suite #
Address
5
Address
N
N
N
N
N
VA
City
State
Zip Code
(If rural address/homeless
describe residence)
Mailing Address
(Provide below)
Residence Address
(Provided in Part #5)
I would like my ballot delivered to:
Fax
(6A-6D only)
(Provide in Part #4)
Email
(6A-6D Only)
(Provide in Part #4)
6
Delivery of
Address
Ballot
APT/Suite #
(See instructions)
N
N
N
N
N
N
N
N
N
-
City
State/Country
Zip Code
Change of
M
M
D
D
Y
Y
Former Full Name
Date Moved
7
/
/
Name/Address
Former Address
(If changing registration
name/address)
8
Assistance
I will need assistance in completing my ballot due to a disability, blindness, or inability to read or write. If checked,
assistance form will be provided with ballot.
To Vote
I swear/affirm, under felony penalty for making willfully false material statements, that the information I have provided on
this form is true and I have written on the Applicant’ s signature line in part #10
“Applicant Unable to
Sign.”
Provide Information of Assistant
Assistant’s
Statement/
9
Full Name
Info
Address
APT/Suite #
(If applicant is unable to
sign due to disability)
N
N
N
N
N
Zip Code
City
State
Signature
I swear/affirm, under felony penalty for making willfully false material statements, that (1) the information I have provided
Applicant
on this form is true, and (2) I am not requesting a ballot or voting in any other jurisdiction in the U.S., except the jurisdiction
10
Signature
to which this application relates.
Today’s
M M
D
D
Y
Y
Signature
/
/
(or mark if unable to sign)
Date
Office Use Only
Application Accepted
Precinct
District/Senate/House
Application #
Yes
No
M
M
D
Y
Y
D
Date Received
/
/
Received By
Reason Not Accepted
Method Received
In Person
By Mail
By Fax
Email
Other
Ballot Sent By
Mail
Email
Fax
In Person
On Machine
Yes
No
SBE-701 Rev. 07/2017
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