Section 1 - Your Personal Information
Section 1 - Your Personal Information Last name:_____________________________ First Name:______________________________ M.I.:______ Address:__________________________________________________________________________________ City:_________________________________ State:____________________________ Zip Code__________ Day Phone:______________________ Evening Phone:___________________ Fax No:_________________ Section 2 - Subject of your complaint Your complaint may be a Virgin Islands or Federal law violation. Common complaints are listed below. Please check off the subject of your complain and explain in detail in Section 3 on the reverse side. Virgin Islands Violations I was not allowed to vote in private. I was not allowed to turn in my absentee ballot. I was not allowed to ask questions or ask for assistance. I was not allowed to vote, even though I was standing in line before the polls closed. I was not able to vote because I was not given assistance to accommodate my disability. I was not able to vote because I was not given assistance in my own language. …
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Section 1 - Your Personal Information Last name:_____________________________ First Name:______________________________ M.I.:______ Address:__________________________________________________________________________________ City:_________________________________ State:____________________________ Zip Code__________ Day Phone:______________________ Evening Phone:___________________ Fax No:_________________ Section 2 - Subject of your complaint Your complaint may be a Virgin Islands or Federal law violation. Common complaints are listed below. Please check off the subject of your complain and explain in detail in Section 3 on the reverse side. Virgin Islands Violations I was not allowed to vote in private. I was not allowed to turn in my absentee ballot. I was not allowed to ask questions or ask for assistance. I was not allowed to vote, even though I was standing in line before the polls closed. I was not able to vote because I was not given assistance to accommodate my disability. I was not able to vote because I was not given assistance in my own language. I was not provided election materials in my own language My voter registration information was altered. I did not observe a sample ballot at the polls. I observed the casting of a fraudulent vote. My polling place was not open on time or not at all. I observed pollworkers acting or saying something discriminatory. I observed inappropriate electioneering or campaigning too close to the polls. I was not allowed to re-vote after I made a mistake. I observed precinct officials neglecting to perform their duties. TEL: (340) 773-1021 / (340) 774-3107 · FAX: (340) 773-4523 / (340) 776-2391 GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES _________________________________________ Elections System of the Virgin Islands __________________________________________ SUNNY ISLE SHOPPING CENTER UNIT 26, ST. CROIX, V.I. / 9200 LOCKHART GARDEN, ST. THOMAS P.O. Box 1499 · Kingshill · St. Croix · U.S. Virgin Islands 00851-1499 P.O. Box 6038 · St. Thomas · U.S. Virgin Islands 00801-6038 Other Virgin Islands Law violation:__________________________________________________________ Federal Law Violations Note: All allegations of Federal law violations must be notarized (see reverse side). The Help America Vote Act (P.L. 107-252) allows individuals to file a complaint if a violation has occurred, is occurring, or is about to occur. I was not allowed to vote using a provisional ballot. Required voting information was not publicly posted in a polling place on Election Day. Other Federal Law Violation:______________________________________________________________ Provisions regarding verification of new voter registration were not followed. I was not able to determined whether my provisional ballot was counted. Your VOTE is your voice. p BOTA ya un ma form. Administrative Complaint Form Please Type or Print all of the information on this form. ) Virgin Islands Section 3 - Details of the Complaint. Explain the details of your complaint, Include names (such as names of any witnesses) addresses (including the address of the polling place), dates, and any other information to fully describe what happened. If you need additional space, please attach a separate sheet. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________________________________ Section 4 - Sign and Attest. I declare under penalty of perjury under the laws of the Virgin Islands that the foregoing is true and correct. Executed on: ___________________ at: _______________________________________________________ (Date) (City /State or Territory) Signature of Person Filing Complaint:___________________________________________________________ For your complaint to be valid, a notary public must complete the following certificate of acknowledgment. ____________________________________________________________ CERTIFICATE OF ACKNOWLEDGMENT ___________________ ) ) SS ) ) On: before me, (Date) (Name of Notary) Personally appeared (Name of Complainant) personally known to me, or proved to me on the basis of satisfactory evidence, to be the person whose name is subscribed above and acknowledged to me that he/she/their executed the same in his/her/their authorized capacity, and that by his/her/their signature the person, or the entity upon hehalf of which the person acted, executed this instrument. WITNESS my hand and official seal. (Notary Seal) (Notary Signature) Return this form to: Elections System of the Virgin Islands __________________________________________ SUNNY ISLE SHOPPING CENTER UNIT 26, ST. CROIX, V.I. / 9200 LOCKHART GARDEN, ST. THOMAS P.O. Box 1499 · Kingshill · St. Croix · U.S. Virgin Islands 00851-1499 P.O. Box 6038 · St. Thomas · U.S. Virgin Islands 00801-6038