EFTA00811470.pdf

L.L1-06. I ILOISI JIJILIVI air II IL 1111A‘11111 I.PLMIIILta Sunny Isle Annex Unit 4 Christiansted, VI I I Box 1499 Kingshill, VI 00851 (340) 773-1021 9200 Lockhart Garden Shopping St. Thomas, VI I Box 6038 St. Thomas, VI 00804 (340) 774-3107 Website: www,vivCite.gew ABSENTEE BALLOT APPLICATION APPLICATION INFORMATION TYPE OR PRINT ONLY Name: Jeffrey E. Epstein Sex: Male ®Female (As listed on the voter Registration Card) Last Four Digits of SS Number: 334 Date of Birth: New Yeti( Place of Birth: New York Party Affiliation: (Select only one) Democrat® Republican 0 ICM No Party® Local Physical Address (No. and Street) Little St. James Island St. Thomas. VI 00802 (As listed on registration card) Local Mailing Address: 6100 Red Hook Quarter B3 St. Thomas, VI 00802 Telephone: Work Home /Cellular_ Fax Email Address: MAIL ABSENTEE BALLOT TO: (Complete mailing address where you want ballot to be mailed) METHOD OF PREFERENCE IN RECEIVING APPLICATION OR BALLOT: WALK-IN MAIIAN 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 c. 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 0 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 Q h. Any person who has not been out of the election district for more than 90 days prior to the date of the election e .,., for which an absentee status is sought ki i. Religious grounds IrIEQUEST AN ABSEIFEE BALLOT FOR THEFOLLOWINGrELECTION(S): LJ 1_1PRIMARY L.C.GENERAL 1_ SPECIAL ALL Elections conducted in the calendar year SIGNATURE OF VOTER or Voter Representative DATE I swear or affirm to the seffiadministered oath, under penalty of perjury that: A. I am a United States Citizen, eligible to vote in the United States Virgin Islands. B. 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. C. I 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) D. That I meet all the qualifications of a Virgin Islands elector. E. The information on this form is true and correct. SIGNATURE OF ELECTOR/VOTER DATE FOR OFFICIAL USE ONLY - Retistered Voter YES NO Baikal Issued Renal Retifined APplitatiOn Rejected REASON: EFTA00811470