Free A2-.pdf - West Virginia

STATE OF WEST VIRGINIA
APPLICANT: Provide all requested information. Please print. Please note: A voter must apply separately for a primary and a general election. State law requires applications to be submitted after the 84th day before an election. (Application must be received by County or Municipal Clerk at least 6 days before the election.) Applying for ballot for: Federal, statewide or Primary election Party ballot (see back) (check one in each column ) county election General election Municipal election Special election scheduled on Name Date of Birth Precinct# Residence Address & County Residence Phone: Email:

Application for Voting an Absent Voter's Ballot by Mail/Fax

Mail Ballot to: (address must be outside county if reason checked is 1,2,6,8,or9) :

Name/Address Change? If you have provided an address or name that is different from that on your voter registration record and you have not informed the county clerk of this change, please indicate the previous information on the line below. You may only do this if you have moved within the county.

I am requesting an absentee ballot for the following reason (check only one numbered box): A. I am not able to vote in person during the early voting period prior to the election and on election day because:
1. Personal or business travel. 2. My attendance at college, university, or other place of education. 3. Illness, injury, or other medical reasons which keep me confined. Please provide the name and telephone number of your doctor who can confirm that you are unable to vote in person.
Doctor's name: Phone:

4. A physical disability or immobility due to extreme advanced age that keeps me confined and unable to vote in person. 5. Incarceration or detention in jail or home. I am not under conviction (including period of probation or parole of any felony, of treason or of bribery in an election. If checking this box, the affidavit on the back of this form must be filled out. 6. I am an absent uniformed services member, spouse or dependent or overseas voter as defined by the Uniformed and Overseas Citizens Absentee Voting Act of 1986; Check here if you are requesting all ballots in an election year. You must apply separately to your city clerk for municipal ballots. I would like to receive my ballot by fax. Fax #: 7. Employment which because of hours worked and distance from the county makes voting in person impossible. B. I am required to live temporarily outside my county of residence because of: 8. Service as an elected or appointed federal or state officer. 9. Temporary assignment by my employer for specific period of four years or less. C. I am not able to vote in person during the 20 days prior to the election and on election day because: 10. The county absentee voting office and the polling place at which I am registered is inaccessible to me because (state reason for inaccessibilty of polling place):

I do hereby certify the information given 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. I understand that knowingly making a false statement on this application is subject to the penalties for false swearing, a fine of up to $1000 and up to one year imprisonment. If I am being assisted with my ballot, the reason for assistance is stated below and the person assisting me has signed this form. RESET
Signature/Mark of Voter (If voter is illiterate, application must be witnessed below) Witness(if voter is illiterate) Form A2 Application for Absentee by Mail (front) Signature of person assisting voter (if needed) Reason for Assistance (if needed) Issued by the Office of the Secretary of State

06/08

STATEMENT OF SHERIFF, CHIEF OF POLICE OR AUTHORIZED DEPUTY [TO BECOMPLETED FORAPPLICANTS VOTING ABSENTEE BECAUSE OF INCARCERATION OR DETENTION.]
I, , bribery, or a felony. , hereby declare that the applicant whose signature appears day of , the date of the election, and is not under conviction of treason,

on this application will be confined in the county or city jail or other detention facility on the

Name of Detention Facility City /County

Signature Title

IMPORTANT REMINDERS TO ALL APPLICANTS! * You may NOT vote in person at the polls on election day if you vote an absentee ballot. * This application must be received by your county clerk (or municipal clerk for city elections) no later than the 6th day before the election in order for a ballot to be mailed to you. * In order to receive the appropriate primary ballot you must note a party choice on the application. Please contact a party representative, your county clerk, or visit www.wvvotes.com for new rules on requesting primary ballots.

Published by: The Office of the Secretary of State Bldg. 1, Suite 157-K 1900 Kanawha Blvd. East Charleston, WV 25305 (304) 558-6000 E-mail: [email protected] Internet Address: www.wvvotes.com

For Office Use Only: Provisional:__________________________ Ballot Received:______________________

Form A2 Application for Absentee by Mail (back)

Issued by the Office of the West Virginia Secretary of State

05/07