Form SBE-703.1 "Annual Absentee Ballot Application - Voter With Disability or Illness" - Virginia

What Is Form SBE-703.1?

This is a legal form that was released by the Virginia Department of Elections - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2016;
  • The latest edition provided by the Virginia Department of Elections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SBE-703.1 by clicking the link below or browse more documents and templates provided by the Virginia Department of Elections.

ADVERTISEMENT
ADVERTISEMENT

Download Form SBE-703.1 "Annual Absentee Ballot Application - Voter With Disability or Illness" - Virginia

Download PDF

Fill PDF online

Rate (4.3 / 5) 89 votes
COMMONWEALTH OF VIRGINIA
‘‘
FOR REGISTRAR USE ONLY
ANNUAL ABSENTEE BALLOT APPLICATION
:
.
#
PCT
APP
DATE THIS APP
RECEIVED
VOTER WITH DISABILITY OR ILLNESS
/
/
:
DATE STATEMENT FILED BY PHYSICIAN
PROVIDER
PRACTIONER
§§ 24.2-700, 24.2-701, 24.2-703.1 and 24.2-704, Code of Virginia
:
:
REGISTERED
YES
NO
REVIEWED BY
FOR COMPLETE INSTRUCTIONS AND DEADLINES SEE REVERSE
SIDE_
:
:
ACCEPTED
YES
NO
REASON DENIED
ABSENTEE VOTER'S STATEMENT --
PART A
I am registered to vote in the
County/ City of:
I am unable to go in person to the polls on election day because of my disability or illness and am likely to remain disabled or ill for
the rest of the calendar year.
• I am applying to receive an absentee ballot for each election in which I am eligible to vote in calendar year 20
.
• I also request ballots for any primary held for nominations of the [check no more than one; if neither party is checked, primary ballots will
not be sent]:
Democratic Party
Republican Party
I WILL NEED ASSISTANCE IN MARKING MY BALLOT due a disability, blindness, or inability to read or write (or need the
ballot translated into another language). [If you check this box, the required form will be sent with your ballot.]
[Check one]:
I am submitting my FIRST Annual Application for an Absentee Ballot and the Statement of Disability or Illness (below) has been
signed by my physician or other state licensed disability services provider or accredited religious practitioner.
This is NOT my first Annual Application. [Part C. Statement of Disability or Illness is not needed for second or later Annual
Applications.]
Send the ballot to me at [check one]:
NOTE: When you return from this temporary address, you must let the Registrar know (by
phone or by filing a revised Annual Application) so that future ballots will be sent to your
The address listed below where I am currently registered. [This
residence. If your ballot is returned as "undeliverable," no additional ballots can be sent
address will be used if no other address is checked or provided.]
until a new application is filed and accepted.
My new Virginia residence address provided on the reverse.
Street Address
The address printed to the right, where I am temporarily
confined due to illness or disability, or where I will be while
outside of my county/city.
City/Town
State
Zip
Note: Ballot cannot be sent "in care of" anyone else. Ballot may only be
sent to the addresses described above.
I declare under felony penalty of law, that, to the best of my
ASSISTANT'S STATEMENT
PART B
[ONLY required if applicant unable to sign due to disability or inability to read or
knowledge, the facts contained in this application are true and
write. Assistance box above should also be checked.]
correct, and that I have not and will not vote in the elections for
I declare, under penalty of law, that:
which I am applying at any other time or place in Virginia or in
• I have written on applicant's signature line:
any other state.
"Applicant Unable to Sign"
Full Name of Absentee Voter
• I have signed and provided requested information below
Full Name of Assistant
Legal Virginia Residence Address
City/Town
Zip
Residence Address of Assistant
Social Security Number [Last 4 digits required]
Area Code
Daytime Phone
City/Town
Zip
Signature of Applicant
Signature of Assistant
Date
STATEMENT OF DISABILITY OR ILLNESS [
This statement is ONLY required for the applicant's FIRST Annual Application.]
PART C
]
[
I,
PRINT NAME
, certify that the above named applicant is unable to go in person
to the polls on election day because of a disability or illness and is likely to remain so disabled or ill for the remainder of the calendar year.
:
:
D
P
:
SIGNATURE
DATE
AYTIME
HONE
[
]:
'
MUST CHECK ONE
I AM THE APPLICANT
S
LICENSED PHYSICIAN
LICENSED DISABILITY SERVICES PROVIDER
ACCREDITED RELIGIOUS PRACTITIONER
[
,
.]
IF YOU HAVE QUESTIONS ABOUT THE QUALIFICATIONS FOR USING THIS APPLICATION OR SIGNING THIS STATEMENT
SEE INSTRUCTIONS ON REVERSE
WARNING: INTENTIONALLY MAKING A MATERIALLY FALSE STATEMENT ON THIS FORM CONSTITUTES THE CRIME OF ELECTION FRAUD,
WHICH IS PUNISHABLE UNDER VIRGINIA LAW AS A FELONY. VIOLATORS MAY BE SENTENCED TO UP TO 10 YEARS IN PRISON, OR UP TO 12
MONTHS IN JAIL AND/OR FINED UP TO $2,500. YOU ALSO LOSE YOUR RIGHT TO VOTE.
Privacy Act Notice: This form requires the last four digits of your social security number for identification and to prevent fraud. Your application will be
denied if you fail to provide this or any other information necessary to determine your qualification to vote. Federal law (the Privacy Act and Help America
Vote Act) and state law (the Virginia Constitution, Article II, § 2, Title 24.2 of the Code of Virginia and the Government Data Collection and Dissemination
Practices Act) authorize collecting this information and restrict its use to official purposes only.
SBE-703.1 REV 08/2016
COMMONWEALTH OF VIRGINIA
‘‘
FOR REGISTRAR USE ONLY
ANNUAL ABSENTEE BALLOT APPLICATION
:
.
#
PCT
APP
DATE THIS APP
RECEIVED
VOTER WITH DISABILITY OR ILLNESS
/
/
:
DATE STATEMENT FILED BY PHYSICIAN
PROVIDER
PRACTIONER
§§ 24.2-700, 24.2-701, 24.2-703.1 and 24.2-704, Code of Virginia
:
:
REGISTERED
YES
NO
REVIEWED BY
FOR COMPLETE INSTRUCTIONS AND DEADLINES SEE REVERSE
SIDE_
:
:
ACCEPTED
YES
NO
REASON DENIED
ABSENTEE VOTER'S STATEMENT --
PART A
I am registered to vote in the
County/ City of:
I am unable to go in person to the polls on election day because of my disability or illness and am likely to remain disabled or ill for
the rest of the calendar year.
• I am applying to receive an absentee ballot for each election in which I am eligible to vote in calendar year 20
.
• I also request ballots for any primary held for nominations of the [check no more than one; if neither party is checked, primary ballots will
not be sent]:
Democratic Party
Republican Party
I WILL NEED ASSISTANCE IN MARKING MY BALLOT due a disability, blindness, or inability to read or write (or need the
ballot translated into another language). [If you check this box, the required form will be sent with your ballot.]
[Check one]:
I am submitting my FIRST Annual Application for an Absentee Ballot and the Statement of Disability or Illness (below) has been
signed by my physician or other state licensed disability services provider or accredited religious practitioner.
This is NOT my first Annual Application. [Part C. Statement of Disability or Illness is not needed for second or later Annual
Applications.]
Send the ballot to me at [check one]:
NOTE: When you return from this temporary address, you must let the Registrar know (by
phone or by filing a revised Annual Application) so that future ballots will be sent to your
The address listed below where I am currently registered. [This
residence. If your ballot is returned as "undeliverable," no additional ballots can be sent
address will be used if no other address is checked or provided.]
until a new application is filed and accepted.
My new Virginia residence address provided on the reverse.
Street Address
The address printed to the right, where I am temporarily
confined due to illness or disability, or where I will be while
outside of my county/city.
City/Town
State
Zip
Note: Ballot cannot be sent "in care of" anyone else. Ballot may only be
sent to the addresses described above.
I declare under felony penalty of law, that, to the best of my
ASSISTANT'S STATEMENT
PART B
[ONLY required if applicant unable to sign due to disability or inability to read or
knowledge, the facts contained in this application are true and
write. Assistance box above should also be checked.]
correct, and that I have not and will not vote in the elections for
I declare, under penalty of law, that:
which I am applying at any other time or place in Virginia or in
• I have written on applicant's signature line:
any other state.
"Applicant Unable to Sign"
Full Name of Absentee Voter
• I have signed and provided requested information below
Full Name of Assistant
Legal Virginia Residence Address
City/Town
Zip
Residence Address of Assistant
Social Security Number [Last 4 digits required]
Area Code
Daytime Phone
City/Town
Zip
Signature of Applicant
Signature of Assistant
Date
STATEMENT OF DISABILITY OR ILLNESS [
This statement is ONLY required for the applicant's FIRST Annual Application.]
PART C
]
[
I,
PRINT NAME
, certify that the above named applicant is unable to go in person
to the polls on election day because of a disability or illness and is likely to remain so disabled or ill for the remainder of the calendar year.
:
:
D
P
:
SIGNATURE
DATE
AYTIME
HONE
[
]:
'
MUST CHECK ONE
I AM THE APPLICANT
S
LICENSED PHYSICIAN
LICENSED DISABILITY SERVICES PROVIDER
ACCREDITED RELIGIOUS PRACTITIONER
[
,
.]
IF YOU HAVE QUESTIONS ABOUT THE QUALIFICATIONS FOR USING THIS APPLICATION OR SIGNING THIS STATEMENT
SEE INSTRUCTIONS ON REVERSE
WARNING: INTENTIONALLY MAKING A MATERIALLY FALSE STATEMENT ON THIS FORM CONSTITUTES THE CRIME OF ELECTION FRAUD,
WHICH IS PUNISHABLE UNDER VIRGINIA LAW AS A FELONY. VIOLATORS MAY BE SENTENCED TO UP TO 10 YEARS IN PRISON, OR UP TO 12
MONTHS IN JAIL AND/OR FINED UP TO $2,500. YOU ALSO LOSE YOUR RIGHT TO VOTE.
Privacy Act Notice: This form requires the last four digits of your social security number for identification and to prevent fraud. Your application will be
denied if you fail to provide this or any other information necessary to determine your qualification to vote. Federal law (the Privacy Act and Help America
Vote Act) and state law (the Virginia Constitution, Article II, § 2, Title 24.2 of the Code of Virginia and the Government Data Collection and Dissemination
Practices Act) authorize collecting this information and restrict its use to official purposes only.
SBE-703.1 REV 08/2016
INSTRUCTIONS FOR COMPLETING THIS FORM
This Annual Absentee Ballot Application may be used by any registered
P
A: A
V
'
S
ART
BSENTEE
OTER
S
TATEMENT
voter who . . .
- Complete the information at the top.
• is unable to go in person to the polls on the day of election because of a
- Print the name of the city/county in which you are registered
to vote.
disability or illness
- Identify the calendar year for which you are applying.
• and is likely to remain disabled or ill for the remainder of the calendar year.
- Indicate if you will need assistance to mark your absentee
Once your application is accepted, a ballot will be mailed to you for every
ballot for the reasons stated. If the box is checked, an
election in which you are eligible to vote, including general elections
Assistance Form will be sent with the absentee ballot. The
and any special elections. You no longer have to apply for a ballot
form,must be returned with the ballot.
separately for each election. But, you will need to submit a new Annual
- Designate a political party preference only if you wish to vote
Application for each year that you remain eligible to use it and wish to
in the political party's primary, if held.
continue voting absentee. (A blank Annual Application will be mailed to you
- Indicate the address where your absentee ballot is to be sent.
each December to apply for the following year.)
[Note the restrictions on ballot mailing addresses.]
- Read the statement that begins "I declare under felony
If you request primary ballots by designating a political party, and any
penalty of law..."
primary is held for that party's nominations, you will also receive that ballot
- Print your full name, current legal residence (street) address,
automatically.
social security number (last 4 digits are required by law) and
Am I required to designate a political party?
daytime telephone number.
• . No. Virginia law does not require a person to identify a political party
- Sign your name and enter the date signed.
preference (Example: Republican Party or Democratic Party) except when
[Note: A signature based on use of a power of attorney
requesting primary ballots. You may vote in either party's primary, but not in
cannot be accepted on this form or any other form
both primaries held on the same day. If you want to change your primary
relating to voter registration or voting.]
ballot request, simply file a new Annual Application before your primary ballot
has been mailed. If you receive a ballot that you do not wish to vote, or need
P
B: A
'
S
ART
SSISTANT
S
TATEMENT
If the absentee voter is unable to sign his or her name:
a replacement ballot, call your Registrar's office for instructions.
- Write on the voter's signature line: "Applicant Unable to Sign."
What are the special requirements for the Annual Application?
- Print the other information required in Part A as the voter directs.
• . On your FIRST Annual Application only, you must have your physician,
- Print your name and address; sign your name.
accredited religious practitioner, or other state licensed disability
services provider (see definitions below) sign and complete the
P
C: S
D
I
ART
TATEMENT OF
ISABILITY OR
LLNESS
Statement of Disability or Illness (Part C of the application). This
- Required only on first Annual Absentee Ballot Application.
Statement is not required on your SECOND or LATER Annual Applications.
- See instructions at left for information on who is authorized to
sign this Statement.
- Person signing Part C should print his or her name, sign, enter
"Accredited religious practitioner" is a person trained in spiritual healing or
the date signed and their daytime phone number, and check the
other healing arts and accredited by a formal religious order. The signature of a
box to indicate their position.
minister who is not so trained and accredited (ordained or otherwise) is not
acceptable. [§24.2-705, Code of Virginia]
P
D: C
N
A
ART
HANGE OF
AME OR
DDRESS
"Other state licensed disability services provider" is a person, entity, or
To remain a qualified voter, state law requires you to notify the
organization (excluding an agency of the federal government) licensed by the
Registrar of a change in your name or address.
Department of Behavioral Health and Developmental Services. "Provider" includes
[Important Note: If the Annual Application or an absentee ballot is
a hospital, community services board, behavioral health authority, private provider,
returned to the Registrar as “Undeliverable” or if the Registrar
and any other similar or related person, entity, or organization. The signature of
knows that you are no longer a qualified voter, no absentee ballot
the person who is a licensed provider or a representative of the licensed entity or
for any subsequent election will be sent to you until a new Annual
organization is acceptable. [§§ 24.2-703.1 and 37.2-403, Code of Virginia]
Application is filed and accepted.
CHANGE OF NAME OR ADDRESS
ADDITIONAL INFORMATION
PART D
Full Name
If Name Changed, Former Full Name
To vote absentee by mail, your application must be
received by your Registrar by 5:00 PM on the
Tuesday before the election.
New Virginia Residence Address
Apt., Suite or Lot No.
Date Moved
Ballots are available 45 days before most elections
City
State
Zip Code
Your voted ballot must be received by the
Electoral Board before the polls close on election
New Mailing Address (if different from New Virginia Residence Address)
day. (Follow the instructions with your ballot.)
For additional information --
Old Virginia Residence Address
Department of Elections
Toll Free 800-552-9745
TTY 800-260-3466
www.elections.virginia.gov
Signature (required)
Social Security Number (Optional)
SBE-703.1 REV 08/2016
\
Page of 2