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Form No. 11-A Prescribed by the Secretary of State (08-17)
print clearly
Absentee Ballot Application R.C. 3509.03
Voter Name Required
Date of Birth Required
Address at Which you are Registered to Vote Required
1 2 3
Mailing Address
Required only if you wish to have your ballot mailed to a different address than the address at which you're registered to vote.
First
Middle
Last
Suffix
Date of Birth (do not write today's date here) Street Address (no P.O.
4
Required
You must provide ONE of the following.
5
Election
box)
ZIP
Your Ohio driver’s license number (2 letters followed by 6 numbers)
OR
Last four digits of your Social Security number
OR
Copy of a current and valid photo identification, military identification, or a current (within the last 12 months) utility bill, bank statement, government check, paycheck or other government document (other than a notice of voter registration mailed by a board of elections) that contains your name and current address. Date of Election (do not write today's date here)
Required
You must complete a separate application for each election.
ZIP
City/Village State
Identification
County
boxes)
City/Village Street Address (or P.O.
MM/DD/YYYY
6
General Election
Special Election
Primary Election For a PARTISAN primary election only, you must choose the type of ballot: Political party ballot Name of Political Party
Affirmation
MM/DD/YYYY
Issues only ballot
• I wish to have an absentee ballot mailed to me at the address listed above.
Required
• I understand this request must be received by my board of elections no later than noon on the Saturday before Election Day if by mail or by 2 p.m. the day before the election if in person. • I understand that if an absentee ballot is mailed to me and I change my mind and go to my polling place to vote on Election Day, I will be required to vote a provisional ballot that cannot be counted until at least 11 days after Election Day.
7
• I understand that, if I do not provide the required information, my application cannot be processed. • I hereby declare, under penalty of election falsification, that I am a qualified elector and the statements above are true. Signature X Today's Date
MM/DD/YYYY
To assist the board of election in contacting you in a timely manner if your application is incomplete, please provide the following information. Telephone Number
E-mail Address
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.