Voter Registration And Information Update Form

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Voter Registration and Information Update Form
Please read instructions carefully. Please type or print clearly with blue or black ink.
For further information, you may consult the Secretary of State’s website at: or call 1-877-767-6446.
Eligibility
Registering by Mail
If you register by mail and do not provide either an Ohio driver’s license
You are qualified to register to vote in Ohio if you meet all the
number or the last four digits of your Social Security number, you must
following requirements:
enclose with your application a copy of one of the following forms of
1. You are a citizen of the United States.
identification:
2. You will be at least 18 years old on or before the day of
the general election.
Current and valid photo identification, a military identification, or
a current (within the last 12 months) utility bill, bank statement,
3. You will be a resident of Ohio for at least 30 days
paycheck, government check or government document (other
immediately before the election in which you want to vote.
than a notice of voter registration mailed by a board of
4. You are not incarcerated (in jail or in prison) for a felony
elections) that shows your name and current address.
conviction.
5. You have not been declared incompetent for voting
Residency Requirements
purposes by a probate court.
Your voting residence is the location that you consider to be a
permanent, not a temporary, residence. Your voting residence is the
6. You have not been permanently disenfranchised for
place in which your habitation is fixed and to which, whenever you
violations of election laws.
are absent, you intend to return. If you do not have a fixed place of
habitation, but you are a consistent or regular inhabitant of a shelter or
Use this form to register to vote or to update your current Ohio
other location to which you intend to return, you may use that shelter
registration if you have changed your address or name.
or other location as your residence for purposes of registering to vote.
If you have questions about your specific residency circumstances, you
NOTICE:
This form must be received or postmarked by the 30th day
may contact your local board of elections for further information.
before an election at which you intend to vote. You will be notified by
your county board of elections of the location where you vote. If you
Your Signature
do not receive a notice following timely submission of this form, please
In the area below the arrow in Box 14, please write your cursive,
contact your county board of elections.
hand-written signature or make your legal mark, taking care that it
does not touch the surrounding lines so when it is digitally imaged by
Numbers 1 and 2 below are required by law. You must answer both
your county board of elections it can effectively be used to identify your
of the questions for your registration to be processed.
signature.
Please see information on back of this form to learn how to
Registering in Person
obtain an absentee ballot.
If you have a current valid Ohio driver’s license, you must provide that
number on line 10. If you do not have an Ohio driver’s license, you must
WHOEVER COMMITS ELECTION FALSIFICATION IS
provide the last four digits of your Social Security number on line 10. If
you have neither, please write “None.”
GUILTY OF A FELONY OF THE FIFTH DEGREE.
FOLD HERE
I am:
Registering as an Ohio voter
Updating my name
Updating my address
1. Are you a U.S. citizen?
Yes
No
2. Will you be at least 18 years of age on or before the next general election?
Yes
No
If you answered NO to either of the questions, do not complete this form.
3. Last Name
First Name
Middle Name or Initial
Jr., II, etc.
4. House Number and Street (Enter new address if changed)
Apt. or Lot #
5. City or Post Office
6. ZIP Code
7. Additional Mailing Address or P.O. Box (if necessary)
8. County (where you live)
FOR BOARD
USE ONLY
SEC4010 (Rev. 6/14)
9. Birthdate (MO-DAY-YR) (required) 10. Ohio Driver’s License No. OR
Ohio driver’s license No. OR
11. Phone No. (voluntary)
City, Village, Twp.
Last Four Digits of Social Security no.
last 4 digits of Social Security No.
(one form of ID required to be listed or provided)
(one form of ID required to be listed or provided)
Ward
12. PREVIOUS ADDRESS IF UPDATING CURRENT REGISTRATION - Previous House Number and Street
Precinct
Previous City or Post Office
County
State
School Dist.
13. CHANGE OF NAME ONLY Former Legal Name
Former Signature
Cong. Dist.
14.
Date
/
/
Your Signature
I declare under penalty of
MO
DAY
YR
Senate Dist.
election falsification I am a
citizen of the United States, will
have lived in this state for 30
House Dist.
days immediately preceding
the next election, and will be
at least 18 years of age at the
time of the general election.

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