ELECTION SYSTEM OF THE VIRGIN ISLANDS

ELECTION SYSTEM OF THE VIRGIN ISLANDS Sunny Isle Annex Unit 4 Christiansted, VI I P.O. Box 1499 Kingshill, w 00851 (340) 773-1021 9200 Lockhart Garden Shopping St. Thomas, VI I P.O. Box 6038 St. Thomas, VI 00804 (340) 774-3107 Website: www.yivOtestox ABSENTEE BALLOT APPLICATION APPLICATION INrORMA1 ION TYPE OR PRINT ONLY Name: Jeffrey E. Epstein (As Maid on MOM. Nernece corm Last Four Digits of SS Number 3348 Sex: Male0Female Date of Birth: 1/J0/51 Mace of Birth: New York Party Affiliation: (Select only one) DemonatO Republican Q 'cm Q No Party® Local Physical Address (No. and Street) Little St. James Island St. Thomas, Virgin Islands 00602 (As listed on registration card) Local Mailing Address: 6100 Red Hook Quarter Ste B3 St Thomas. Wirt Islands 00602 Home TelephoneM Mork Fax /Cellular Email Addres MAIL ABSENTEE BALLOT TO: (Complete mailing address where you wont ballot to be mailed) 575 Lexington Avenue 41h Floor New York, New York 10022 METHOD OF PREFERENCE IN RECEIVING APPLICATION OR BALLOT: WALK-IN mffitIN 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 V.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 P. My person who has not been out of the election disffict for more than 9O days prior to the date of the election e ..‘ for which an absentee status is sought k. .1 i. Religious grounds IrtEQVEST AN ABSEfiltrxi BALLOT FOR pa-FOLLOWING ION(S): Lj PRIMARY I" (GENERAL SPECIAL AU:Elections conducted in the calendar year SIGNATUR • VOTER or /a 17r -(3 DATE I swear or affirm to the sel , under penalty of perjury that: A. I am a United States Citizen, e e 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 informa n this form is true and cone GNATURE OF EL /04 //J DATE FOR OFFICIAL USE ONLY -- Rnpistered Voter YES NO B.4ot Issued Woe Returned Applotbn Rejected MASON: EFTA00304538