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ELECTIONS DEPARTMENT of VIRGINIA (Pittsylvania County Virginia)

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Virginia Absentee Ballot
Application Form
VIRGINIA
DEPARTMENT
ELECTIONS
of
WARNING:INTENTIONALLY VOTING MORE THAN ONCE IN AN
ELECTION OR 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.
Privacy Act Notice:
This form collects personal information, including your social
security number, for identification and to prevent fraud. Your
application will be denied if you fail to provide the last four
digits of your social security number or any other information
required to determine your qualification to vote absentee.
Federal law (the Privacy Act) and state law (Va. Code § 24.2-
701 and the Government Data Collection and Dissemination
Practices Act) authorize collecting this information and restrict
its use to official purposes only.
SBE-701 Rev. 07/2015
Department of Elections Contact Info:
Phone: (804) 864-8901 Toll Free: (800) 552-9745
Fax: (804) 371-0194
Email: info@elections.virginia.gov
TTY: 711
You can check the status of your absentee ballot
request and ballot by calling your local General
Registrar, the Department of Elections toll free
number or checking through the Department of
Elections website: elections.virginia.gov
!
SBE-701 Rev. 07/01/2015
Page 2
Accomack County
PO Box 97
Accomac, VA 23301-0097
(757) 787 • 2935
Albemarle County
PMB 404, 536 Pantops Center
Charlottesville, VA 22911
(434) 972 • 4173
Alexandria City
132 North Royal St, Ste. 100
Alexandria, VA 22314-3283
(703) 746 • 4050
Alleghany County
110 Rosedale Ave, Ste. D
Covington, VA 24426-1294
(540) 965 • 1690
Amelia County
PO Box 481
Amelia, VA 23002-0481
(804) 561 • 3460
Amherst County
PO Box 550
Amherst, VA 24521-0550
(434) 946 • 9315
Appomattox County
PO Box 8
Appomattox, VA 24522-0008
(434) 352 • 5302
Arlington County
2100 Clarendon Blvd, Ste. 320
Arlington, VA 22201-5400
(703) 228 • 3456
Augusta County
PO Box 590
Verona, VA 24482-0590
(540) 245 • 5656
Bath County
PO Box 157
Warm Springs, VA 24484-0157
(540) 839 • 7266
Bedford County
County Admin Building
122 East Main St, Ste. 204
Bedford, VA 24523-2000
(540) 586 • 7649
Bland County
PO Box 535
Bland, VA 24315-0535
(276) 688 • 4441
Botetourt County
PO Box 62
Fincastle, VA 24090-0062
(540) 473 • 8235
Bristol City
300 Lee St
Bristol, VA 24201-4327
(276) 645 • 7318
Brunswick County
100 Tobacco St, Rm. 103
Lawrenceville, VA 23868-1823
(434) 848 • 4414
Buchanan County
PO Box 975
Grundy, VA 24614-0975
(276) 935 • 6534
Buckingham County
PO Box 222
Buckingham, VA 23921-0222
(434) 969 • 4304
Buena Vista City
2039 Sycamore Ave
Buena Vista, VA 24416-3133
(540) 261 • 8605
Campbell County
PO Box 103
Rustburg, VA 24588-0103
(434) 332 • 9579
Caroline County
PO Box 304
Bowling Green, VA 22427-0304
(804) 633 • 9083
Carroll County
Governmental Center
605-3 Pine St, B 110
Hillsville, VA 24343-1404
(276) 730 • 3035
Charles City County
PO Box 146
Charles City, VA 23030-0146
(804) 652 • 4606
Charlotte County
PO Box 118
Charlotte CH, VA 23923-0118
(434) 542 • 5856
Charlottesville City
PO Box 911
Charlottesville, VA 22902-0911
(434) 970 • 3250
Chesapeake City
411 Cedar Rd
Chesapeake, VA 23322-5566
(757) 277 • 9797
Chesterfield County
PO Box 1690
Chesterfield, VA 23832-1690
(804) 748 • 1471
Clarke County
PO Box 555
Berryville, VA 22611-0555
(540) 955 • 5168
Colonial Heights City
PO Box 3401
Colonial Heights, VA 23834-9001
(804) 520 • 9277
Covington City
515 E. Pine St
Covington, VA 24426-1534
(540) 965 • 6380
Craig County
PO Box 8
New Castle, VA 24127-0008
(540) 864 • 6190
Culpeper County
151 North Main St, Ste. 301
Culpeper, VA 22701
(540) 825 • 0652
Cumberland County
PO Box 125
Cumberland, VA 23040-0008
(804) 492 • 4504
Danville City
515 Main St
Danville, VA 24541-1317
(434) 799 • 6560
Dickenson County
PO Box 1306
Clintwood, VA 24228-1306
(276) 926 • 1620
Dinwiddie County
PO Box 365
Dinwiddie, VA 23841-0365
(804) 469 • 4500 option 7
Emporia City
PO Box 1092
Emporia, VA 23847-1092
(434) 634 • 9533
Essex County
PO Box 1561
Tappahannock, VA 22560-1561
(804) 443 • 4611
Fairfax County
12000 Govt Ctr Pkwy, Ste. 323
Fairfax, VA 22035-0081
(703) 222 • 0776
Fairfax City
Sisson House
10455 Armstrong St
Fairfax, VA 22030-3640
(703) 385 • 7890
Falls Church City
300 Park Ave, Rm. 101E
Falls Church, VA 22046-3332
(703) 248 • 5085
Fauquier County
32 Waterloo St, Ste. 207
Warrenton, VA 20186-3238
(540) 422 • 8290
Floyd County
100 East Main St, Rm. 302
Floyd, VA 24091-2101
(540) 745 • 9350
Fluvanna County
PO Box 44
Palmyra, VA 22963-0044
(434) 589 • 3593
Franklin County
1255 Franklin St, Ste. 106
Rocky Mount, VA 24151-1289
(540) 483 • 3025
Franklin City
PO Box 42
Franklin, VA 23851-0042
(757) 562 • 8545
Frederick County
107 North Kent St, Ste. 102
Winchester, VA 22601-5039
(540) 665 • 5660
Fredericksburg City
Executive Plaza
601 Caroline St, Ste. 500-A
Fredericksburg, VA 22401
(540) 372 • 1030
Galax City
PO Box 1045
Galax, VA 24333-1045
(276) 236 • 7509
Giles County
201 N. Main St, Ste. 1
Pearisburg, VA 24134-1611
(540) 921 • 2802
Gloucester County
PO Box 208
Gloucester, VA 23061-0208
(804) 693 • 3659
Goochland County
PO Box 1013
Goochland, VA 23063-1013
(804) 556 • 5803
Grayson County
PO Box 449
Independence, VA 24348-0449
(276) 773 • 2842
Greene County
PO Box 341
Stanardsville, VA 22973-0341
(434) 985 • 5213
Greensville County
PO Box 1092
Emporia, VA 23847-1092
(434) 348 • 4228
Halifax County
PO Box 400
Halifax, VA 24558-0400
(434) 476 • 3322
Hampton City
1919 Commerce Dr, Ste. 280
Hampton, VA 23666
(757) 727 • 6218
Hanover County
PO Box 419
Hanover, VA 23069-0419
(804) 365 • 6080
Harrisonburg City
PO Box 20031
Harrisonburg, VA 22801-7531
(540) 432 • 7707
Henrico County
PO Box 90775
Henrico, VA 23273-0775
(804) 501 • 4347
Henry County
PO Box 7
Collinsville, VA 24078-0007
(276) 638 • 5108
Highland County
PO Box 386
Monterey, VA 24465-0386
(540) 468 • 2013
Hopewell City
309 North 2nd Ave
Hopewell, VA 23860-2704
(804) 541 • 2232
Isle of Wight County
PO Box 77
Isle of Wight, VA 23397-0077
(757) 365 • 6230
James City County
PO Box 3567
Williamsburg, VA 23187-3567
(757) 253 • 6868
King & Queen County
PO Box 56
King & Queen CH, VA 23085-
0056
(804) 785 • 5980
King George County
PO Box 1359
King George, VA 22485-1359
(540) 775 • 9186
King William County
PO Box 173
King William, VA 23086-0173
(804) 769 • 4952
Lancaster County
PO Box 159
Lancaster, VA 22503-0159
(804) 462 • 5277
Lee County
PO Box 363
Jonesville, VA 24263-0363
(276) 346 • 7780
Lexington City
PO Box 922
Lexington, VA 24450-0922
(540) 462 • 3706
Loudoun County
750 Miller Drive, SE, Ste. C
Leesburg, VA 20175-8916
(703) 777 • 0380
Louisa County
PO Box 220
Louisa, VA 23093-0220
(540) 967 • 3427
Lunenburg County
160 Courthouse Sq
Lunenburg, VA 23952-9999
(434) 696 • 3071
Lynchburg City
3236 Odd Fellows Rd
Lynchburg, VA 24501
(434) 477 • 5999
Madison County
PO Box 267
Madison, VA 22727-0267
(540) 948 • 6533
Manassas City
9025 Center St
Manassas, VA 20110-5403
(703) 257 • 8230
Manassas Park City
City Hall. 1 Park Center Ct
Manassas Park, VA 20111-2395
(703) 335 • 8806
Martinsville City
PO Box 1323
Martinsville, VA 24114-1323
(276) 403 • 5122
Mathews County
PO Box 328
Mathews, VA 2310
(804) 725 • 3200
Mecklenburg County
PO Box 436
Boydton, VA 23917-0436
(434) 738 • 6191
Middlesex County
PO Box 358
Saluda, VA 23149-0358
(804) 758 • 4420
Montgomery County
755 Roanoke St, Ste. 1F
Christiansburg, VA 24073-3175
(540) 382 • 5741
Nelson County
PO Box 292
Lovingston, VA 22949-0292
(434) 263 • 4068
New Kent County
PO Box 128
New Kent, VA 23124-0128
(804) 966 • 9699
Newport News City
2400 Washington Ave
Newport News, VA 23607-4305
(757) 926 • 8683
Norfolk City
PO Box 1531
Norfolk, VA 23501-1531
(757) 664 • 4353
Northampton County
PO Box 510
Eastville, VA 23347-0510
(757) 678 • 0480
Northumberland County
PO Box 84
Heathsville, VA 22473-0084
(804) 580 • 4655
Norton City
PO Box 225
Norton, VA 24273-0225
(276) 679 • 1162
Nottoway County
PO Box 24
Nottoway, VA 23955-0024
(434) 645 • 8148
Orange County
146 Madison Rd, Ste. 204
Orange, VA 22960-1449
(540) 672 • 5262
Page County
551 Mechanic St
Luray, VA 22835-1820
(540) 743 • 3986
Patrick County
PO Box 635
Stuart, VA 24171-0635
(276) 694 • 7206
Petersburg City
PO Box 1031
Petersburg, VA 23804-1031
(804) 733 • 8071
Pittsylvania County
110 Old Chatham Elementary Ln
Chatham, VA 24531
(434) 432 • 7971
Poquoson City
500 City Hall Ave, Rm. 139
Poquoson, VA 23662-1996
(757) 868 • 3070
Portsmouth City
801 Crawford St,1st Fl
Portsmouth, VA 23704-3822
(757) 393 • 8644
Powhatan County
3834 Old Buckingham Rd, Ste. G
Powhatan, VA 23139-7051
(804) 598 • 5604
Prince Edward County
PO Box J
Farmville, VA 23901
(434) 392 • 4767
Prince George County
PO Box 34
Prince George, VA 23875-0034
(804) 722 • 8748
Prince William County
9250 Lee Ave, Suite 1
Manassas, VA 20110-5554
(703) 792 • 6470
Pulaski County
87 Commerce St.
Pulaski, VA 24301-5045
(540) 980 • 2111
Radford City
619 2nd St
Radford, VA 24141
(540) 731 • 3639
Rappahannock County
PO Box 236
Washington, VA 22747-0236
(540) 675 • 5380
Richmond County
PO Box 1000
Warsaw, VA 22572-1000
(804) 333 • 4772
Richmond City
PO Box 61037
Richmond, VA 23261-1037
(804) 646 • 5950
Roanoke County
PO Box 20884
Roanoke, VA 24018-0089
(540) 772 • 7500
Roanoke City
215 Church Ave SW, Ste. 109
Roanoke, VA 24011-1518
(540) 853 • 2281
Rockbridge County
150 S. Main St
Lexington, VA 24450
(540) 463 • 7203
Rockingham County
20 E. Gay St
Harrisonburg, VA 22802-4108
(540) 564 • 3055
Russell County
PO Box 383
Lebanon, VA 24266-0383
(276) 889 • 8006
Salem City
PO Box 203
Salem, VA 24153-0203
(540) 375 • 3034
Scott County
PO Box 1892
Gate City, VA 24251-3417
(276) 386 • 3843
Shenandoah County
600 N. Main St, Ste. 103
Woodstock, VA 22664
(540) 459 • 6195
Smyth County
121 Bagley Cir, Ste. 108
Marion, VA 24354
(276) 783 • 4511
Southampton County
PO Box 666
Courtland, VA 23837-0666
(757) 653 • 9280
Spotsylvania County
PO Box 133
Spotsylvania, VA 22553-0133
(540) 507 • 7380
Stafford County
PO Box 301
Stafford, VA 22555-0301
(540) 658 • 4000
Staunton City
PO Box 58
Staunton, VA 24402-0058
(540) 332 • 3840
Suffolk City
PO Box 1966
Suffolk, VA 23439-1966
(757) 514 • 7750
Surry County
PO Box 264
Surry, VA 23883-0264
(757) 294 • 5213
Sussex County
PO Box 1302
Sussex, VA 23884-0302
(434) 246 • 1047
Tazewell County
PO Box 201
Tazewell, VA 24651-0201
(276) 385 • 1305
Virginia Beach City
PO Box 6247
Virginia Beach, VA 23456-0247
(757) 385 • 8683
Warren County
220 North Commerce Ave,
Ste. 700
Front Royal, VA 22630
(540) 635 • 4327
Washington County
1 Government Ctr Pl,Suite A
Abingdon, VA 24211-7466
(276) 676 • 6227
Waynesboro City
250 S. Wayne Ave, Ste. 205
Waynesboro, VA 22980
(540) 942 • 6620
Westmoreland County
PO Box 354
Montross, VA 22520-0354
(804) 493 • 8898
Williamsburg City
PO Box 3538
Williamsburg, VA 23187-3538
(757) 220 • 6157
Winchester City
107 N. East Lane
Winchester, VA 22601-5072
(540) 545 • 7910
Wise County
PO Box 309
Wise, VA 24293-0309
(276) 328 • 8331
Wythe County
2
45 South Fourth St, Ste. 101
Wytheville, VA 24382-2598
(276) 223 • 6038
York County
PO Box 451
Yorktown, VA 23690-0451
(757) 890 • 3440
Voter Registration Offices
(General Registrar)
7/01/2015
2
Election
I am applying to vote in:
General or Special Election Democratic Primary
3
More Info
(Optional)
4
Birth Year
Telephone
Y
Y
Y
Y
--
Residence
Address
(If rural address/homeless
describe residence)
Address
5
Delivery of
Ballot
(See instructions)
Applicant
Signature
I swear/affirm, under felony penalty for making willfully false material statements, that (1) the information I have provided
on this form is true, and (2) I am not requesting a ballot or voting in any other jurisdiction in the U.S., except the jurisdiction
to which this application relates.
10
Signature (or mark if unable to sign)
Supporting Info
StateCity
Reason for
Absentee Ballot
M
M
/
D
D
/
Y
Y
9
Provide Information of Assistant
Unless otherwise indicated, all items on this form are required. Please print clearly. Instructions on page 4.
*
Republican Primary
Reason Code
Instructions on reason
codes are on page 4
!
Your application will be denied if a qualifying reason and
required information are not provided.
*
Address
6
Zip CodeState/CountryCity
Assistant’s
Statement/
Info
(If applicant is unable to
sign due to disability)
I swear/affirm, under felony penalty for making willfully false material statements, that the information I have provided on
this form is true and I have written on the Applicant’s signature line in part #10 “Applicant Unable to Sign.”
Address
StateCity
Full Name
Date of Election
M
M
/
D
D
/
Y
Y
County City
Signature
Change of
Name/Address
(If changing registration
name/address)
7
Former Address
Former Full Name
Date Moved
M
M
/
D
D
/
Y
Y
Office Use Only
Precinct District/Senate/House Application #
Application Accepted
Yes
No
Date Received
M
M
/
D
D
/
Y
Y
Received By
Method Received
In Person By Mail By Fax Email Other
Reason Not Accepted
Ballot Sent By
Mail Email In Person
Yes NoOn Machine
SBE-701 Rev. 07/2015
Page 3
Virginia Absentee Ballot Application Form
Assistance
To Vote
I will need assistance in completing my ballot due to a disability, blindness, or inability to read or write. If checked,
assistance form will be provided with ballot.
8
APT/Suite #
!
Upon completion of the form, return this page only to the address on page 2 for the city/county where you are applying.
I am registered to vote in the
of
(if required)
Your Name
& SSN
1
Last Name
First Name
Middle Name
Suffix
Social Security #
-
(Last 4 digits required)
I would like my ballot delivered to:
Residence Address (Provided in Part #5)
Mailing Address (Provide below)
Email (6A-6D Only) (Provide in Part #4)
Fax (6A-6D only) (Provide in Part #4)
Fax
N
N
N
N
N
N
N
N
N
APT/Suite #
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Zip Code
N
N
N
N
N
Zip Code
N
N
N
N
N
Today’s
Date
Email/Fax
-
APT/Suite #
VA
N
N
N
N
-
Mail to: Pittsylvania County Voter Registration - 110 Old Chatham Elementary Lane, Chatham, VA 24531
Code Reason Supporting Information Required
1A
Student attending college or university outside of locality of residence in
Virginia
Name of college or university
1B
Spouse of student attending college or university outside locality of resi-
dence in Virginia
Name of college or university
1C Business outside County/City of residence on election day Name of employer or business
1D
Personal business or vacation outside County/City of residence on elec-
tion day
Place of travel (VA county/city or state or country)
1E
I am working and commuting to/from home for 11 or more hours be-
tween 6:00 AM and 7:00 PM on election day
Name of employer or business and election day hours
of working and commuting (AM to PM)
1F
I am a first responder (member of law enforcement, fire fighter,
emergency technician, search and rescue)
Not required
2A My disability or illness Not required
2B
I am primarily and personally responsible for the care of a disabled/ill fam-
ily member confined at home
Family Relationship
2C My pregnancy Not required
3A Confined, awaiting trial Name of institution
3B Confined, convicted of a misdemeanor Name of institution
4A
An electoral board member, registrar, officer of election, or custodian of
voting equipment
Not required
5A I have a religious obligation Not required
6A Active Duty Merchant Marine or Armed Forces Branch of service
6B Spouse or dependent living with a member of 6A Branch of service
6C Temporarily residing outside of US
Enter your last date of residency at your Virginia
voting residence only if you have given up that
address permanently or have no intent to return
6D
Temporarily residing outside of US for employment or spouse or
dependent residing with employee
Name of business or employer
7A
Requesting a ballot for presidential and vice-presidential electors only
(Ballots for other offices/issues will not be sent)
New state of residence and date moved from
Virginia. Only eligible if you moved less than 30 days
before the presidential election.
8A
Authorized representative of candidate or party serving inside the polling
place
Not required
!
To vote absentee you must be a registered voter of the city/county where you are applying
To Vote Absentee
Select only one Code from the list of reason codes below. Write
in the selected code on the form in part #3 and include any
supporting information required. A separate form is required
for each voter and for each election.
First-Time Voters
First-time voters who registered by mail may vote absentee by
mail only if the reason code is 1A, 2A, 2C, 6A, 6B, 6C, 6D, or 7A,
or the voter is 65 or older and qualifies under another reason.
Absent Military and Overseas Voters
You are encouraged to use the Federal Post Card Application
(FPCA) which also serves as a voter registration application. To
obtain the FPCA and information, visit www.fvap.gov.
Submitting this Virginia Absentee Ballot Application form will
be interpreted as a request by you to discontinue any pending
FPCA.
Apply Early
You can apply to vote absentee as early as one year before
the election. Ballots are available 45 days before most
elections. If you register to vote in person, you must wait
five days before you can vote in person or have your bal-
lot mailed to you.
The deadline for receipt of your application to vote absentee
by mail is 5:00 PM the Tuesday before the election. Please
mail this application to your general registrar listed on page
2. Please do not return this application to the State Board
of Elections. You may also submit your application by fax or
scanned email attachment.
The deadline to apply and vote absentee in-person is the
Saturday before the election. Contact your general registrar
for office or satellite office address and voting locations.
SBE-701 Rev. 07/2015
Page 4
Delivery of Ballot
Your ballot can only be mailed to one of the following:
(1) Voter’s residence address
(2) Voter’s location while outside voter’s residence county/city; or
(3) Place of temporary confinement for illness, disability,
misdemeanor conviction or awaiting trial
No ballot may be sent in care of any other person.
Instructions
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ELECTIONS DEPARTMENT of VIRGINIA (Pittsylvania County Virginia)

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Completed 14 February 2021

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