A person with a disability or illness who has applied for and has been sent an absentee ballot who did not receive or has lost the absentee ballot on or before the Saturday before the election may obtain a replacement absentee ballot. In such case, the voter may request a replacement absentee ballot by the close of business for the local elections office on the Saturday before election day and designate, in writing, a representative to obtain a replacement absentee ballot on his behalf from the general registrar and to return the properly completed ballot as directed by the general registrar no later than the close of polls on the day of election for which the absentee ballot is valid. The representative shall be age 18 or older and shall not be an elected official, a candidate for elected office, or the deputy, spouse, parent, or child of an elected official or candidate. The voter and representative shall complete the form prescribed by the State Board to implement the provisions of this section. The form shall include a statement signed by the voter that he did not receive the ballot or has lost the ballot. Statements on the form shall be subject to felony penalties for making false statements pursuant to § 24.2-1016.