Form 10-L - Notice Of Name Change printable pdf download

Form No. 10-L Prescribed by Secretary of State (06-14)

NOTICE OF CHANGE OF NAME

R.C. 3503.16(B)(1)(b)

_________________________________________________________

Voter’s new legal name:

Voter’s former name: ________________________________________________________________

Voting residence address:

Street Address__________________________________________________________________________

City, Village, or Post Office ________________________________________________________________

County ________________________________________________

Zip Code ______________________

Birth date ____________/___________/__________

(Month)

(Day)

(Year)

Your Ohio driver’s license number___________________________, or, if you do not have a driver’s license,

(begins with two alphabet letters followed by six numbers)

The last four digits of your Social Security number ______________, or, if you have neither,

Please check this box indicating that you have none of the above.

I hereby declare, under penalty of election falsification, I am a citizen of the United States, have lived in this state

for 30 days immediately preceding this election, and am at least 18 years of age.

____________________________________________________

__________________________________

(Signature of Voter)

(Date Signed)

Your former signature: ______________________________________

WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.

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INSTRUCTIONS TO PRECINCT ELECTION OFFICIAL:

1. Verify the address provided by the voter above matches the address printed in the pollbook. If the addresses are

different, but the address above is in your precinct (based on the precinct street listing), then the voter may cast a

regular ballot. If the addresses are different and the address above is not in your precinct, direct the voter to the

correct precinct where they may cast a provisional ballot.

2. Check the appropriate box indicating type of legal proof of name change provided:

Marriage license

Court order

Other: _________________________________________________

3. Precinct Election Official Signature: ______________________________________

Form 10-L - Notice Of Name Change