1 Form No. 11-A Prescribed by the Secretary of State (08-17) print clearly Absentee Ballot Application R.C. 3509.03 Voter Name First Middle Required 1 Last Suffix Date of Birth Date of Birth (do not write today's date here) 2 Required Address at Which County Street Address (no P.O. boxes) you are Registered 3 to Vote Required ZIP City/Village Mailing Address (or P.O. box) Street Address only if you wish to Required have your ballot mailed to a different address than the address at which you're City/Village 4 registered to vote. State ZIP Identification (2 letters followed by 6 numbers) Your Ohio driver’s license number OR Required ONE of the You must provide Last four digits of your Social Security number OR following. 5 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 contains your name and current address. Election (do not write today's date here) Date of Election Required Special Election General Election You must complete a separate 6 application for each election. Primary Election For a PARTISAN primary election only, you must choose the type of ballot: Issues only ballot Name of Political Party Political party ballot Affirmation • I wish to have an absentee ballot mailed to me at the address listed above. Required • I understand this request must be received by my board of elections no later than noon on the Saturday before Election Day if by mail or by 2 p.m. the day before the election if in person. • I understand that if an absentee ballot is mailed to me and I change my mind and go to my polling place to vote on Election Day, I will be required to vote a provisional ballot that cannot be counted until at least 11 days after Election Day. • I understand that, if I do not provide the required information, my application cannot be 7 processed. • I hereby declare, under penalty of election falsification, that I am a qualified elector and the statements above are true. Signature X Today's Date To assist the board of election in contacting you in a timely manner if your application is incomplete, please provide the following information. Telephone Number E-mail Address WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.
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