Form No. 11-A Prescribed by Secretary of State (11-11)

Application for Absent Voter’s Ballots
 PLEASE PRINT OR TYPE
 (See Instructions at bottom of page)

PRINT OUT THIS FORM, COMPLETE  IT, MAIL TO: 
Ottawa County Board of Elections
8444 W. State Route 163, Suite 101

Oak Harbor, Ohio 43449-8885

Board Use Only

County No. ___________________________________

Precinct _____________________________________

School District ____________ Ballot No. ___________

Date Issued ____________ Date Received __________

 

Voter's Name_________________________________

Home Address________________________________

     

City or Village ________________________________

County_______________Zip Code________________

Send Ballots to: (if different from home address)
              

Name_______________________________________
        
Care of/P.O. Box_______________________________
         
Address_____________________________________

    

City____________________State_____Zip_________

 

You MUST provide your birth date _____________/____________/_____________ and ONE of the following:                                                                      month                 day                    year

Check ONE:   

q   Your Ohio driver's license number _____________________ , or
q The last four digits of your social security number ___________________ , or
 q 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 voter registration notification mailed by a board of elections) that shows your name and address.

.

I wish to vote in the following election to be held on _________________________.

                                                                                             (Month-Date-Year of Election)

Check ONLY one (A separate application must be completed for each election):

    1. Primary Election 

            Party_______________________________    Nonpartisan or issues only_______________________________                                                                                                                               

  2. q General Election

   3. q Special Election

I wish to have a ballot mailed to me at the address listed above.  I understand that if a ballot is mailed to me and I

 change my mind and appear at my polling place to vote on Election Day, I will be required to vote a provisional

 ballot that can not be counted until at least 10 days after the election.

I hereby declare, under penalty of election falsification, I am a qualified voter 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 ___________________________________________________          ___________________________

                                               SIGNATURE OF VOTER                                                     Date Signed

Voluntary: To assist the board of elections in contacting you in a timely manner if your application is incomplete:

 Your daytime telephone number____________________      Your E-mail address__________________________

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

INSTRUCTIONS   Chapter 3509 of the Revised Code of Ohio

 

1.  An application by mail must be received by your county board of elections by noon on the third day before the election. An application by you in person must be received by the close of regular board hours the day before the election. Applications for persons who are hospitalized or for a persons whose minor child is hospitalized due to an accident or unforeseeable medical emergency will be accepted until 3 p.m. on election day.

2.  If you return your ballot by mail, it must be postmarked* no later than the day before Election Day and received by your county board of elections no later than 10 days after the election.  If you return your ballot in person or if a near relative delivers it to the board for you, it must be delivered to your county  board of elections no later than the close of polls on Election Day.  If you are a voter outside of the United States on Election Day, the ballot envelope must be signed or postmarked before the close of polls and received by the board no later than 10 days after Election Day or 20 days after a presidential primary election.

*Postmarked does not include a date marked by a postage evidence system such as a postage meter.            

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