Elections System of the Virgin Islands 
Sunny Isle Shopping Center, Christiansted, St. Croix, V.I. (340) 773-1021 Lockhart 
Gardens, St. Thomas, V.I. (340) 774-3107 
P.O. Box 1499, Kingshill, St. Croix, U.S. Virgin Islands 00851 / P.O. Box 6038, St. Thomas, U.S. Virgin Islands 00801 
Instructions: Please complete this form to remove the following name from the list of registered voters in the 
U.S. Virgin Islands. Areas marked with an asterisk (*) are required, however all information on this form can help 
locate your Voter’s Registration. 
*Reason for Cancellation: (Select One)
Voter has moved out of state. 
New State/Territory of Residence:  
Voter no longer wishes to be registered to vote in the U.S. Virgin Islands. 
Voter is deceased. 
Date of Death (MM/DD/YYYY):  
/ 
_  / 
_ _  
Was there an obituary posted? 
 Yes 
 No 
If voter is deceased, relationship to deceased voter: 
*Full Name:
Physical Address of Registration: 
_ 
District of Registration: 
Last 4 of SSN: 
*Date of Birth (MM/DD/YYYY):
/ 
/ 
_ _ 
*Oath:
I,  
, swear or affirm that the Voter Registration information 
provided above is true and accurate to the best of my knowledge. I hereby request this Voter Registration be 
cancelled for this voter, effective as of the date this form is received by the Elections System of the Virgin Islands. I 
understand that this voter will no longer be eligible to vote in the U.S. Virgin Islands unless you re-register to vote. 
*Signature:
*Date:
/ 
/ 
THIS VOTER WILL NOT BE REMOVED UNLESS THIS FORM IS SIGNED BY THE VOTER OR A RELATIVE OF A DECEASED VOTER, AS REQUIRED UNDER FEDERAL LAW. 
FOR OFFICIAL USE ONLY 
YOUR REQUEST FOR CANCELLATION OF YOUR REGISTRATION HAS BEEN GRANTED BY THE SUPERVISOR OF 
ELECTIONS. 
ELECTIONS SYSTEM OFFICES ARE AT SUNNY ISLES SHOPPING CENTER UNIT 26, ST. CROIX, LOCKHART GARDENS, 
ST. THOMAS, OR MARKET PLACE THIRD FLOOR, ST. JOHN. FOR ADDITIONAL INFORMATION CONTACT (340) 773- 
1021 OR (340) 774-3107. 
ELECTION OFFICIAL’S SIGNATURE AND DATE 
SIGN
SIGN