ELECTION SYSTEM OF THE VIRGIN ISLANDS Sunny Isle Annex Unit 4 Christiansted, VI | MM} Box 1499 Kingshal, vi cogs 9200 Lockhart Garden Shopping St. Thomas, Vi | JMNM Box 6038 St. Thomas, vi 00804 ES Website: ABSENTEE BALLOT APPLICATION ea APPLICATION INFORMATION ones TYPE OR PRINT ONLY (Ws Este on the voter Regiowetion Cord) Last Four Digits of SS Number: MN __ Date of Birth: 7/2// 87 _ Place of Birth: Belons Party Affiliation: (Select only one) Democrat(.) _Republican(_) mC) No Party(®) Local Physical Address (No. and Street) 6B Little St. James, St. Thomas, Virgin Islands 00802 {As listed on registration card) Local Mailing Address: 6100 Red Hook Quarter Ste B3, St. Thomas, Virgin Islands 00802-1348 Telephone: /Work /Home EE cettutar _/ Fax cat Address: oon MAIL ABSENTEE BALLOT TO: (Complete mailing address where you want ballot to be mailed) 575 Lexington Avenue 4th Floor New York, New York 10022 METHOD OF PREFERENCE IN RECEIVING APPLICATION OR BALLOT: WALK-IN__ MAIL-4N___ E-Mail (MILITARY ONLY) _ REASON FOR ABSENTEE BALLOT (MARK X ONLY ONE): a. Member of the Armed Forces and Spouse or dependent b. A student residing outside the Territory ¢. An officer or employee of the Government of the Virgin Islands or Government of the U.S. d. Unable to appear because of illness or physical disability (permanent or temporary) e. A patient in a hospital, nursing home or home for the aged f. Absent from District because of accompanying a spouse, parent or child who would be entitled to apply for the right to vote by Absentee ballot Oz Detained in jail awaiting action by a grand jury or trial, or has been confined in prison after a conviction for an offense other than a felony On Any person who has not been out of the election district for more than 90 days prior to the date of the election for which an absentee status is sought lon Religious grounds iJ ALL Elections conducted in the calendar year 1043 bore DATE 1 swear or affirm to the self-administered oath, under penalty of perjury that: | am a United States Citizen, eligible to vote in the United States Virgin Islands. I have not been convicted of a felon or other disqualifying offense or been adjudicated mentally incompetent, or if so my voting rights have been reinstated. | am not requesting a ballot from or voting in any other State, Territory, or Possession or Subdivision of the United States or Foreign country in the coming election(s) qualifications of a Virgin Islands elector. on this form is true and correct. rp 9 => EFTA00520764