ELECTION SYSTEM OF THE VIRGIN ISLANDS Sunny Isle Annex Unit 4 Christiansted, VI | P.O. Box 1499 Kingshill, VI 00851 (340) 773-1021 9200 Lockhart Garden Shopping St. Thomas, VI | P.O. Box 6038 St. Thomas, VI 00804 (340) 774-3107 Website: www.vivote.gov ABSENTEE BALLOT APPLICATION TYPE OR PRINT ONLY Name: Karyna Shuliak Sex: Mate(_Femate @), (As sted om the voter Registration Card) Last Four Digits of SS Number: 4819 __Datte of Birth: Zf1{%) Place of Birth: Befaw wes Party Affiliation: (Select only one) Democrat Q Republican Q ICM Q 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 83, St. Thomas, Virgin Islands 00802-1348 Telephone: /Work /Home cettuiar Fax email Address: I 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-IN____ E-Mail (MILITARY ONLY) _ FOR MARK X ONLY Member of the Armed Forces and Spouse or dependent . A student residing outside the Territory . An officer or employee of the Government of the Virgin Islands or Government of the U.S. . Unable to appear because of illness or physical disability (permanent or temporary) . A patient in a hospital, nursing home or home for the aged 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 Q g. 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 © h. 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 oO i. Religious grounds a ABS awn N(S): IMAI PY leenenat ALL Elections conducted in the calendar year SIGNATURE OF VOTER or Voter Representative DATE meandg® | swear or affirm to the self-administered oath, under penalty of perjury that: A. lama United States Citizen, eligible to vote in the United States Virgin Islands. B. Ihave not been convicted of a felon or other disqualifying offense or been adjudicated mentally incompetent, or if so my voting rights have been reinstated. C. | 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) That | meet all the qualifications of a Virgin Islands elector. The information on this form is true and correct. mo SIGNATURE OF ELECTOR/VOTER DATE F E ONLY -- Regi YES EFTA00522193