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Commonwealth o Virginia

Virginia Absentee Ballot Application Form

24.2-700 and 24.2-701, Code o Vi

Application or Absentee BallotINSTRUCTIONS

omplete all required inormation in Parts A-D, and Parts E-F, i applicable. Otherwise, your application cannot be processed.

TOP OF FORM

omplete the inormation at the top. You mustBe a registered voter in the county/city where you are applying.Identiy the election or which you are applying.

PART A

o vote absentee, select only one code rom the list o reasonodes. Write in the selected code and include any required

normation to support the reason (this inormation is required bytate law). Note: First time voters who registered by mail may votebsentee by mail only i the reason code in Part A is 1A, 2A, 2C,A, 6B, 6C, 6D or 7A, or the voter is 65 or older and qualifes undernother reason.

PART Brint the address where your absentee ballot is to be sent, i votingy mail. The ballot can only be sent to:The address where the voter will be while out o their county/city; orThe address where the voter is temporarily confned due to anillness or disability; orThe address where the voter is currently registered or newlyregistered; orThe address where the voter is confned awaiting trial or havingbeen convicted o a misdemeanor.A military or overseas voter (reasons 6A, 6B, 6C or 6D) may ask toreceive their ballot by e-mail or ax.

The ballot cannot be sent in care o any other person.PART C

Indicate i assistance rom another person will be needed tovote the ballot due to the voters disability, blindness or inabilityto read or write. I Yes is checked, an Assistance Form will besent with the absentee ballot. The orm, to be returned with theballot, provides a legal saeguard or the voter and the assistant.

PART D

Absentee Voter: Read the Statement in Part D. Then print yourull name, current residence (permanent) home address, socialsecurity number (last 4 digits required) and a daytime telephone

number. Sign your name. I applying in person, the applicationmust be signed in the presence o a registrar or a member othe electoral board. Note: A signature under a power of attorneycannot be accepted. (Also see Part E.)

PART E

Assistant: i the absentee voter is unable to sign his/her namedue to a disability, blindness or inability to read or write, the

assistant must write on the voters signature line:

Applicant Unable to Sign. Assistant must complete and sigPart E. Assistant should also ensure that the rest o theapplication is complete.

PART F

To remain a qualifed voter, state law requires you to notiy thGeneral Registrar o a change in your name or address. ComPart F and sign your name.

ATTENTION VOTERS

Apply early! You can apply to vote absentee as early as oneyear beore the election. You can apply in person at your city

or county voter registration ofce or by sending a completedapplication by mail, ax, or a scanned copy. Ballots are availa45 days beore Primary and General elections and mostSpecial Elections.

I applying and voting by mail, allow enough time or yourapplication to be processed and your ballot mailed to you.The deadline or applying to vote absentee by mail is 5:00 PMthe Tuesday beore the election. All ballots must be receivedthe Electoral Board by 7:00 PM on election day. I returning tballot to the Electoral Board in person, only the voter may return

The deadline or applying and casting your ballot in-person at y

local voter registration ofce is the Saturday beore the electiVisit the State Board o Elections website,http://www.sbe.virginia.gov or:

Contact inormation or your local voter registration ofce Inormation about absentee voting The status o your absentee application

(under Voter Inormation, Registration Status).

Toll Free 800 552 9745 (TTY 800 260 3466).

ATTENTION MILITARY & OVERSEAS VOTER

You are encouraged to use the Federal Post Card Application

(FPCA) which also serves as a voter registration application.To obtain the FPCA orm and inormation, visithttp://www.vap.gov. Submitting this Virginia Absentee BalloApplication orm will be interpreted as a request by you todiscontinue any pending FPCA. You can submit a new FPCA iyou are eligible.

rivacy Act Notice: This orm collects personal inormation, including your social security number, or identifcation and to prevent raud. Your applicationwill be denied i you ail to provide the last our digits o your social security number or any other inormation required to determine your qualifcation to vot

bsentee. Federal law (the Privacy Act) and state law (Va. Code 24.2-701 and the Government Data Collection and Dissemination Practices Act) authorizeollecting this inormation and restrict its use to ofcial purposes only.

WARNING: INTENTIONALLY MAKING A MATERIALLY FALSE STATEMENT ON THIS FORM CONSTITUTES THE CRIME OF ELECTION FRAUD, WHICH IS

UNISHABLE UNDER VIRGINIA LAW AS A FELONY. VIOLATORS MAY BE SENTENCED TO UP TO 10 YEARS IN PRISON, OR UP TO 12 MONTHS IN JAIL ANDINED UP TO $2,500. SBE-701 Re

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ccomack CountyPO Box 97Accomac, VA 23301-0097(757) 787 2935lbemarle CountyPMB 404, 536 Pantops CenterCharlottesville, VA 22911(434) 972 4173lexandria City132 North Royal St, Ste. 100Alexandria, VA 22314-3283(703) 746 4050lleghany County110 Rosedale Ave, Ste. DCovington, VA 24426-1294(540) 965 1690melia CountyPO Box 481Amelia, VA 23002-0481(804) 561 3460mherst CountyPO Box 550Amherst, VA 24521-0550(434) 946 9315ppomatox CountyPO Box 8Appomatox, VA 24522-0008(434) 352 5302rlington County2100 Clarendon Blvd, Ste. 320Arlington, VA 22201-5400(703) 228 3456ugusta CountyPO Box 590Verona, VA 24482-0590(540) 245 5656ath CountyPO Box 157

Warm Springs, VA 24484-0157(540) 839 7266edord CountyCounty Admin Building122 East Main St, Ste. 204Bedord, VA 24523-2000(540) 586 7649edord City215 East Main StBedord, VA 24523-2012(540) 587 6007land CountyPO Box 535Bland, VA 24315-0535(276) 688 4441otetourt CountyPO Box 62Fincastle, VA 24090-0062(540) 473 8235ristol City300 Lee StBristol, VA 24201-4327

(276) 645 7318runswick County100 Tobacco St, Rm. 103Lawrenceville, VA 23868-1823(434) 848 4414uchanan CountyPO Box 975Grundy, VA 24614-0975(276) 935 6534uckingham CountyPO Box 222Buckingham, VA 23921-0222(434) 969 4304uena Vista City2039 Sycamore AveBuena Vista, VA 24416-3133(540) 261 8605ampbell CountyPO Box 103Rustburg, VA 24588-0103(434) 332 9579aroline County

PO Box 304Bowling Green, VA 22427-0304(804) 633 9083arroll CountyGovernmental Center605-3 Pine St, B 110Hillsville, VA 24343-1404(276) 730 3035harles City CountyPO Box 146Charles City, VA 23030-0146(804) 652 4606harlotte CountyPO Box 118Charlotte CH, VA 23923-0118(434) 542 5856harlottesville CityPO Box 911Charlottesville, VA 22902-0911(434) 970 3250hesapeake City411 Cedar RdChesapeake, VA 23322-5566(757) 277 9797

Chesterfeld CountyPO Box 1690Chesterfeld, VA 23832-1690(804) 748 1471

Clarke CountyPO Box 555Berryville, VA 22611-0555(540) 955 5168

Colonial Heights CityPO Box 3401Colonial Heights, VA 23834-9001(804) 520 9277

Covington City515 E. Pine StCovington, VA 24426-1534(540) 965 6380

Craig CountyPO Box 8New Castle, VA 24127-0008

(540) 864 6190Culpeper County151 North Main St, Ste. 301Culpeper, VA 22701(540) 825 0652

Cumberland CountyPO Box 125Cumberland, VA 23040-0008(804) 492 4504

Danville City515 Main StDanville, VA 24541-1317(434) 799 6560

Dickenson CountyPO Box 1306Clintwood, VA 24228-1306(276) 926 1620

Dinwiddie CountyPO Box 365Dinwiddie, VA 23841-0365(804) 469 4500 ext. 2113

Emporia CityPO Box 1092Emporia, VA 23847-1092(434) 634 9533

Essex CountyPO Box 1561Tappahannock, VA 22560-1561(804) 443 4611

Fairax County12000 Govt Ctr Pkwy, Ste. 323Fairax, VA 22035-0081(703) 222 0776

Fairax CitySisson House10455 Armstrong StFairax, VA 22030-3640(703) 385 7890

Falls Church City300 Park Ave, Rm 101EFalls Church, VA 22046-3332(703) 248 5085

Fauquier County32 Waterloo St, Ste. 207Warrenton, VA 20186-3238

(540) 422 8290Floyd County

100 East Main St, Rm. 302Floyd, VA 24091-2101(540) 745 9350

Fluvanna CountyPO Box 44Palmyra, VA 22963-0044(434) 589 3593

Franklin County1255 Franklin St, Ste. 106Rocky Mount, VA 24151-1289(540) 483 3025

Franklin CityPO Box 42Franklin, VA 23851-0042(757) 562 8545

Frederick County107 North Kent St, Ste. 102Winchester, VA 22601-5000(540) 665 5660

Fredericksburg City

Executive Plaza601 Caroline St, Ste. 100Fredericksburg, VA 22401(540) 372 1030

Galax CityPO Box 1045Galax, VA 24333-1045(276) 236 7509

Giles County201 N. Main St, Ste. 1Pearisburg, VA 24134-1611(540) 921 2802

Gloucester CountyPO Box 208Gloucester, VA 23061-0208(804) 693 3659

Goochland CountyPO Box 1013Goochland, VA 23063-1013(804) 556 5803

Grayson CountyPO Box 449

Independence, VA 24348-0449(276) 773 2842

Greene CountyPO Box 341Stanardsville, VA 22973-0341(434) 985 5213

Greensville CountyPO Box 1092Emporia, VA 23847-1092(434) 348 4228

Haliax CountyPO Box 400Haliax, VA 24558-0400(434) 476 3322

Hampton City1919 Commerce Dr, Ste. 280Hampton, VA 23666(757) 727 6218

Hanover CountyPO Box 419Hanover, VA 23069-0419

(804) 365 6080Harrisonburg City20 E. Gay StHarrisonburg, VA 22802-4108(540) 432 7707

Henrico CountyPO Box 90775Henrico, VA 23273-0775(804) 501 4347

Henry CountyPO Box 7Collinsville, VA 24078-0007(276) 638 5108

Highland CountyPO Box 386Monterey, VA 24465-0386(540) 468 2013

Hopewell City309 North 2nd AveHopewell, VA 23860-2704(804) 541 2232

Isle o Wight CountyPO Box 77Isle o Wight, VA 23397-0077(757) 365 6230

James City CountyPO Box 3567Williamsburg, VA 23187-3567(757) 253 6868

King & Queen CountyPO Box 56King & Queen CH, VA 23085-0056(804) 785 5980

King George CountyPO Box 1359King George, VA 22485-1359(540) 775 9186

King William CountyPO Box 173King William, VA 23086-0173(804) 769 4952

Lancaster CountyPO Box 159Lancaster, VA 22503-0159(804) 462 5277

Lee CountyPO Box 363Jonesville, VA 24263-0363(276) 346 7780

Lexington CityPO Box 922Lexington, VA 24450-0922(540) 462 3706

Loudoun County750 Miller Drive, SE, Ste. CLeesburg, VA 20175-8916(703) 777 0380

Louisa CountyPO Box 220Louisa, VA 23093-0220(540) 967 3427

Lunenberg County160 Courthouse SqLunenberg, VA 23952-9999(434) 696 3071

Lynchburg City3236 Odd Fellows Rd

Lynchburg, VA 24501(434) 847 1609

Madison CountyPO Box 267Madison, VA 22727-0267(540) 948 6533

Manassas City9025 Center StManassas, VA 20110-5403(703) 257 8230

Manassas Park CityCity Hall. 1 Park Center CtManassas Park, VA 20111-2395(703) 335 8806

Martinsville CityPO Box 1323Martinsville, VA 24114-1323(276) 403 5122

Mathews CountyPO Box 328Mathews, VA 23109-0328(804) 725 3200

Mecklenburg CountyPO Box 436Boydton, VA 23917-0436(434) 738 6191

Middlesex CountyPO Box 358Saluda, VA 23149-0358(804) 758 4420

Montgomery County755 Roanoke St, Ste. 1FChristiansburg, VA 24073-3175(540) 382 5741

Nelson CountyPO Box 292Lovingston, VA 22949-0292(434) 263 4068

New Kent CountyPO Box 128New Kent, VA 23124-0128

(804) 966 9699Newport News City2400 Washington AveNewport News, VA 23607-4305(757) 926 8683

Norolk CityPO Box 1531Norolk, VA 23501-1531(757) 664 4353

Northampton CountyPO Box 510Eastville, VA 23347-0510(757) 678 0480

Northumberland CountyPO Box 84Heathsville, VA 22473-0084(804) 580 4655

Norton CityPO Box 225Norton, VA 24273-0225(276) 679 1162

Nottoway County

PO Box 24Nottoway, VA 23955-0024(434) 645 8148

Orange County146 Madison Rd, Ste. 204Orange, VA 22960-1449(540) 672 5262

Page County117 South Court StLuray, VA 22835-1289(540) 743 3986

Patrick CountyPO Box 635Stuart, VA 24171-0635(276) 694 7206

Petersburg CityPO Box 1031Petersburg, VA 23804-1031(804) 733 2380

Pittsylvania County110 Old Chatham Elementary LnChatham, VA 24531(434) 432 7971

Poquoson City500 City Hall Ave, Rm. 139Poquoson, VA 23662-1996(757) 868 3070

Portsmouth City801 Craword St,1st FlPortsmouth, VA 23704-3822(757) 393 8644

Powhatan County3834 Old Buckingham Rd, Ste. GPowhatan, VA 23139-7051(804) 598 5604

Prince Edward CountyPO Box JFarmville, VA 23901(434) 392 4767

Prince George CountyPO Box 34Prince George, VA 23875-0034(804) 722 8748

Prince William County9250 Lee Ave, Suite 1

Manassas, VA 20110-5554(703) 792 6470

Pulaski County52 West Main St, Ste. 300Pulaski, VA 24301-5045(540) 980 2111

Radord City619 2nd StRadord, VA 24141(540) 731 3639

Rappahannock CountyPO Box 236Washington, VA 22747-0236(540) 675 5380

Richmond CountyPO Box 1000Warsaw, VA 22572-1000(804) 333 4772

Richmond CityPO Box 61037Richmond, VA 23261-1037(804) 646 5950

Roanoke CountyPO Box 20884Roanoke, VA 24018-0089(540) 772 7500

Roanoke CityPO Box 1095Roanoke, VA 24005-1095(540) 853 2281

Rockbridge County150 S. Main StLexington, VA 24450(540) 463 7203

Rockingham County20 E. Gay StHarrisonburg, VA 22802-410(540) 564 3055

Russell CountyPO Box 383Lebanon, VA 24266-0383

(276) 889 8006Salem CityPO Box 203Salem, VA 24153-0203(540) 375 3034

Scott CountyPO Box 1892Gate City, VA 24251-3417(276) 386 3843

Shenandoah County600 N. Main St, Ste. 106Woodstock, VA 22664(540) 459 6195

Smyth County121 Bagley Cir, Ste. 108Marion, VA 24354(276) 783 4511

Southampton CountyPO Box 666Courtland, VA 23837-0666(757) 653 9280

Spotsylvania CountyPO Box 133Spotsylvania, VA 22553-013(540) 507 7380

Staord CountyPO Box 301Staord, VA 22555-0301(540) 658 4000

Staunton CityPO Box 58Staunton, VA 24402-0058(540) 332 3840

Suolk CityPO Box 1966Suolk, VA 23439-1966(757) 514 7751

Surry CountyPO Box 264Surry, VA 23883-0264(757) 294 5213

Sussex CountyPO Box 1302Sussex, VA 23884-0302(434) 246 1047

Tazewell CountyPO Box 201Tazewell, VA 24651-0201(276) 988 1305

Virginia Beach CityPO Box 6247Virginia Beach, VA 23456-02(757) 385 8683

Warren County220 North Commerce Ave, Ste. Front Royal, VA 22630(540) 635 4327

Washington County25552 Lee Hwy, Ste. 1Abingdon, VA 24211-7466(276) 676 6227

Waynesboro City250 S. Wayne Ave, Ste 205Waynesboro, VA 22980

(540) 942 6620Westmoreland County

PO Box 354

Montross, VA 22520-0354(804) 493 8898

Williamsburg CityPO Box 3538Williamsburg, VA 23187-353(757) 220 6157

Winchester City107-A N. East LaneWinchester, VA 22601-5072(540) 545 7910

Wise CountyPO Box 309Wise, VA 24293-0309(276) 328 8331

Wythe County245 South Fourth St, Ste. 10Wytheville, VA 24382-2598(276) 223 6038

York CountyPO Box 451Yorktown, VA 23690-0451(757) 890 3440

st o Voter Registration OfcesGeneral Registrar) as o 4/19/2011

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Supporting Inormation Required

Name and address o school attending

Name and address o school spouse is attending

Name o employer or business

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

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

and workplace addressNot required

Nature o disability or illness

Name o amily member and nature o disability/illness

Not required

Place and address o confnement

Place and address o confnement

Not required

Religion and nature o obligation

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

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

I your Virginia residence is no longer available to you,provide your last date o residence in Virginia

Name o business or employer; i your Virginia residence is nolonger available to you, provide your last date o residence in Virg

Not required

Must provide name o designating candidate or party

Ballot to be: Mailed E-mailed Voted in person (On machine: YES NO)

recinct: District/Sen/House: Application number: Reviewed by:

OR OFFICE USE ONLY

eceived: In person By mail By ax Other Reason not accepted:Application accepted: YES NO

ate received:

Virginia Absentee Ballot ApplicationSubmit a separate orm or each person and or each election. Must Complete Parts A through D (and E/F i applicable).

/ /Y Y YYD DMM

am applying to vote in:Check one (Required) To be held on

I am registered to vote in the (Required)

General Electionor Special Election

Democratic Primary Republican Primary

/ /Y Y YYD DMM

Under Virginia law a registered voter may qualiy to vote absentee by completing one o theollowing statements. Note: First time voters who registered by mail may be ineligible to apply to voabsentee by mail. See Instructions page.

PART A

I will be absent on Election Day rom the county/city in which I am registered to vote (reasons 1A, 1B, 1C, 1D, 6A, 6

6C or 6D), or will be unable to go to the polls on Election Day (other reasons except 7A) because:

Code Supporting Inormation (Required for all codes except 1F, 2C, 4A or 7A)

OVER

Printed Full Name o Absentee Voter (Required)

Code

1A

1B

1C

1D

1E

1F

2A

2B

2C

3A

3B

4A

5A

6A

6B

6C

6D

7A

8A

Reason

Student

Spouse o student

Business

Personal business or vacation

I am working and commuting to/rom home or 11 or more

hours between 6:00 AM and 7:00 PM on Election DayI am a frst responder (member o law enorcement,fre fghter, emergency technician, search and rescue)

My disability or illness

I am primarily and personally responsible or the care o adisabled/ill amily member confned at home

My pregnancy

Confned, awaiting trial

Confned, convicted o a misdemeanor

An electoral board member, registrar, ofcer o election,

or custodian o voting equipmentI have a religious obligation

Active Duty Merchant Marine or Armed Forces

Spouse or dependent living with a member o 6A

Temporarily residing outside o US

Temporarily residing outside o US or employment orspouse or dependent residing with employee

Requesting a ballot or presidential and vice-presidentialelectors only (Ballots or other ofces/issues will not be sent)

Designated representative o candidate or party inside polls

Required

County/ City o: - -Social Security Number(last 4 digits required)

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PART E Assistants Statement (Required only i voter received assistance in completing this application due

a disability, blindness, or inability to read or write.)I declare, under elony penalty o law, that I have written on Applicants Signature line in Part D: Applicant Unable to Sign. I have signed and provided requested inormation below.

Signature o Assistant

Address o Assistant

Printed Full Name o Assistant

City/Town Zip Code

PART F Change o Name or Address

New Virginia Residence (Permanent) Home Address

Date Moved rom Old Addres

Mailing Address i dierent rom New Virginia Residence Address (if Rural Address or if you are a Protected Voter)

I Name Changed, Former Full Name

Old Virginia Residence (Permanent) Home Address

ull Name

Signature (Required)

/ /Y Y YYD DMM

PART 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 ollowing address. (See the instructions page or addresses allowed.)

treet Address City/Town State Zip Code

PART C Assistance I will need assistance in completing my ballot due to a disability, blindness, or inabilityto read or write.

PART D Absentee Voters Statement

I declare under elony penalty that, to the best o my knowledge, the acts contained in this application are trueand correct, and that I have not, and will not vote in this election at any other place in Virginia or in any other statKnowingly giving any untrue inormation in this document is a elony under Virginia law. The maximum penalty isfne o $2500 and/or confnement or up to ten years.

applicant is unable to sign due to a physical disability, write the name/address o person who assisted in Part E (required).Check here i submitting a change o name or address in Part F.

DateSignature o Registered Voter (Required)

- -

ocial Security Numberast 4 digits required)

Year o Birth Daytime Telephone Number- -

E-mail Address or Fax Number

Residence (Permanent/Currently Registered) Home AddressThis address will be used if no other address is checked or provided inPart B.

Printed Full Name o Voter (Required)/ /

Y YYD DMM

City/Town State Zip CodeApt/Unit/Lot/Ste

mail/Fax only i reason in Part A is 6A, 6B, 6C or 6D.

VA

City/Town State Zip CodeApt/Unit/Lot/Ste

VA

State

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