Form 11-E - Application By Relative For Uniformed Services Or Overseas Absent Voter'S Ballot

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Form No. 11-E Prescribed by Secretary of State (06-14)
APPLICATION BY RELATIVE
FOR UNIFORMED SERVICES OR OVERSEAS ABSENT VOTER’S BALLOT
R.C. 3511.02(C)
This completed form must be delivered in person or by mail to the board of elections. It may not be e-mailed or faxed.
I, _______
_____________________________
, residing at _____________________________________,
(Printed name of relative)
(Street and number, or rural route number)
_____________________________________________ hereby apply to have an absent voter’s ballot
(City or Village, State and Zip Code)
mailed, e-mailed, or faxed to _______________________________________, a qualified elector who is:
(Name of uniformed services or overseas voter)
a uniformed services voter
an overseas voter
His/her voting residence is:______
_____________________________
, ____________________________.
(Street and Number, or Rural Route Number)
(City or Village and Zip Code)
The voter has resided at that residence for ________
__________,
immediately preceding the voter’s
(Length of time)
commencement of service or departure from the United States.
I am the _____
_____________________________
of the person to whom the ballot is to be sent.
(Relationship to uniformed services or overseas voter)
Uniformed Services or Overseas voter’s birth date: _________/_______/_______
(month)
(day)
(year)
One of the Uniformed Services or Overseas voter’s following forms of ID:
Ohio driver’s license number
_________
_________________,
or
(begins with two letters followed by six numbers)
The last four digits of the voter’s Social Security number ___
_________________,
or
Copy of a current and valid photo identification, a 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 the voter’s name and current address.
The voter wishes to vote in 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
____
___________________
_
(Name of political party)
2.
General Election
3.
Special Election
Mail the Ballot to: _____
______________________
or, Fax Ballot to:_
_______________________
or,
(Area Code) (Fax Number)
E-mail Ballot to:
_________________________________
I declare, under penalty of election falsification, the above statements are true, to the best of my
knowledge and belief. I understand that if I do not provide the requested information, this application cannot
be processed.
X_____________________________________________
____________________________
(Signature of Relative
(Date Signed)
)
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE

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