Form 11-I - Application For Absent Voter'S Ballot Under R.c. 3503.16 By Voter With Unreported Change Of Address And/or Name
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1Form No. 11-I Prescribed by Secretary of State (09-14)
APPLICATION FOR ABSENT VOTER’S BALLOT UNDER R.C. 3503.16
BY VOTER WITH UNREPORTED CHANGE OF ADDRESS AND/OR NAME
R.C. 3503.16(G), R.C. 3509.02(B), R.C. 3509.08(A)
Voter’s current name: ___________________________________________________________________
I am currently registered to vote in Ohio (check all that apply):
At a different address
Under a different name
I am unable to appear at the board of elections office to update my Ohio voter registration because of the
following described personal illness, physical disability, or infirmity _____________________________________.
Address at which you currently reside:
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 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 check primary election, select the type of ballot):
Party ___________________________
Issues only
(Name of political party)
2.
General Election
3.
Special Election
Complete the following statement only if it applies to you:
I am unable to mark my ballot without assistance because of the illness, physical disability or infirmity described above.
Please have two election officials deliver my ballot to me at (check ONE):
my current 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 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 have moved or had a change of name on or prior to the day before
the election. I understand that if I do not provide the requested information, my application cannot be processed.
X
X
____________________________________________________
__________________________________
(Signature of Voter)
(Date Signed)
If applicable, your former name, _____________________________,and signature________________________________
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.
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