ELECTION SYSTEM OF THE VIRGIN ISLANDS

ELECTION SYSTEM OF THE VIRGIN ISLANDS Sunny Isle Annex Unit a Christiansted, VI I P.O. Box 1499 kingshill, VI 038511340) 773-1021 9200 Locehan Garden Shopping St. Thomas, VII D.O. Box 6038 St. Thomas, VI 00809 (390) 774-3107 Website: ABSENTEE BALLOT APPLICATION APPLICATION INFORMATION TYPE OR PRINT ONLY Name: Karyna Shuliak (as bled co the Tom meistration case) Last Four Digits of SS Number: 4619 Date of Birth: pr/34( NI Place of Birth: &AS nes Party Affiliation: (Select only one) Democrat Q Republican() ICMO No Party® Sex: Male® Female Local Physical Address (No. and Street) GB 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 /Cellular Fax Email Address: 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 APPUCATION OR BALLOT: WAUCIN mAIL-IN E-Mail (MILITARY ONLY) REASON FOR ABSENTEE BALLOT (MARK X ONLY ONth 1 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 0 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 Q i. Religious grounds II.REQUEST AN ABSEnBALLOT FOR 111FIFOLLOWING 'TION(S): Lj PRIMARY GENERAL L_ISPECIAL _ ALL Elections conducted In the calendar year SIGNATURE OF VOTER or Voter Representative DATE I swear or affirm to the self-administered 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 - Reentered Voter YES NO Pallet issued Ballot Retuned Appfatton Rejected REASON: EFTA00522193