Form No. 11-A Prescribed by the Secretary of State (08-17)
Absentee Ballot Application
print clearly
R.C. 3509.03
Voter Name
Required
1
First Middle
Last Suffix
Date of Birth
Required
2
Date of Birth (do not write today's date here)
Address at Which
you are Registered
to Vote
Required
3
Street Address (no P.O. boxes)
County
City/Village
ZIP
Mailing Address
Required only if you wish to
have your ballot mailed to a
different address than the
address at which you're
registered to vote.
4
Street Address (or P.O. box)
City/Village
State
ZIP
Identification
Required
You must provide ONE of the
following.
5
Your Ohio driver’s license number (2 letters followed by 6 numbers)
OR
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
contains your name and current address.
Election
Required
You must complete a separate
application for each election.
6
Date of Election (do not write today's date here)
General Election
Primary Election
Special Election
For a PARTISAN primary election only, you must choose the type of ballot:
Political party ballot
Name of Political Party
Issues only ballot
Affirmation
Required
7
I wish to have an absentee ballot mailed to me at the address listed above.
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
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.
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
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