Form 11-F - Application For Absent Voter'S Ballot By Voter Requiring Assistance
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1Form No. 11-F Prescribed by Secretary of State (06-14)
APPLICATION FOR ABSENT VOTER’S BALLOT
BY VOTER REQUIRING ASSISTANCE
R.C. 3509.08 (A)
Voter’s Name______________________________________________________________________________
Voting Residence Street Address_____________________________________________________________
City, Village, or Post Office __________________________________________________________________
County ____________________________________________
Zip Code _____________________________
You must provide your birth date: ____________/___________/__________ and one of the following:
(month)
(day)
(year)
Your Ohio driver’s license number___________________________, or
(begins with two letters followed by six numbers)
The 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 shows your name and current address.
I wish to vote at the election to be held on: ___________________________.
(month-date-year of election)
Check ONLY one election (A separate application must be completed for each election):
1.
Primary Election
(If you checked primary election, select the type of ballot):
Party
Issues only
2.
General Election
3.
Special Election
Check one:
I am unable to mark my ballot without assistance because of the following described illness, physical
disability or infirmity:__________________________________________________________________
I am confined in a jail or workhouse
Please have two election officials deliver my ballot to me at (check ONE):
my voting residence listed above; or
my present place of confinement in this county:
_____________________________________________________________________,
(Name of facility)
_____________________________________________________________________,
(Street name and number – Room number)
______________________________________________, OH ___________________.
(City or Village)
(Zip Code)
I understand this request must be received by my county board of elections by mail no later than noon the third day before
the date of the election listed above.
I hereby declare, under penalty of election falsification, that I am a qualified elector and the statements above are
true to the best of my knowledge and belief. I understand that if I do not provide the requested information, my
application cannot be processed.
X
X
____________________________________________________
__________________________________
(Signature of Voter)
(Date Signed)
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.
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