Voter Registration and Information Update Form
Please read instructions carefully. Please type or print clearly with blue or black ink.
For further information, you may consult the Secretary of State’s website at: www.OhioSecretaryofState.gov or call 1-877-767-6446.
Eligibility
You are qualied to register to vote in Ohio if you meet all the
following requirements:
1. You are a citizen of the United States.
2. You will be at least 18 years old on or before the day of
the general election.
3. You will be a resident of Ohio for at least 30 days
immediately before the election in which you want to vote.
4. You are not incarcerated (in jail or in prison) for a felony
conviction.
5. You have not been declared incompetent for voting
purposes by a probate court.
6. You have not been permanently disenfranchised for
violations of election laws.
Use this form to register to vote or to update your current Ohio
registration if you have changed your address or name.
NOTICE: This form must be
received or postmarked
by the 30th day
before an election at which you intend to vote. You will be notied by
your county board of elections of the location where you vote. If you
do not receive a notice following timely submission of this form, please
contact your county board of elections.
Numbers 1 and 2 below are required by law. You
must
answer
both
of the questions for your registration to be processed.
Registering in Person
If you have a current valid Ohio driver’s license, you must provide that
number on line 10. If you do not have an Ohio driver’s license, you must
provide the
last four digits
of your Social Security number on line 10. If
you have neither, please write “None.”
Registering by Mail
If you register by mail and do not provide either a current Ohio driver’s
license number or the last four digits of your Social Security number,
please enclose with your application a copy of one of the following
forms of identication that shows your name and current address:
Current valid photo identication card, military identication, or
current (within one year) utility bill, bank statement, paycheck,
government check or government document (except board of
elections notications) showing your name and current address.
Residency Requirements
Your voting residence is the location that you consider to be a
permanent, not a temporary, residence. Your voting residence is the
place in which your habitation is xed and to which, whenever you
are absent, you intend to return. If you do not have a xed place of
habitation, but you are a consistent or regular inhabitant of a shelter or
other location to which you intend to return, you may use that shelter
or other location as your residence for purposes of registering to vote.
If you have questions about your specic residency circumstances, you
may contact your local board of elections for further information.
Your Signature
In the area below the arrow in Box 14, please write your cursive,
hand-written signature or make your legal mark, taking care that it
does not touch the surrounding lines so when it is digitally imaged by
your county board of elections it can effectively be used to identify your
signature.
Please see information on back of this form to learn how to
obtain an absentee ballot.
WHOEVER COMMITS ELECTION FALSIFICATION IS
GUILTY OF A FELONY OF THE FIFTH DEGREE.
FOLD HERE
1. Are you a U.S. citizen? Yes No
2. Will you be at least 18 years of age on or before the next general election? Yes No
If you answered NO to either of the questions, do not complete this form.
3. Last Name
First Name Middle Name or Initial Jr., II, etc.
4. House Number and Street (Enter new address if changed)
Apt. or Lot # 5. City or Post Ofce 6. ZIP Code
7. Additional Rural or Mailing Address (if necessary) 8. County (where you live)
9. Birthdate (MO-DAY-YR) (required) 10. Ohio driver’s license No. OR 11. Phone No. (voluntary)
last 4 digits of Social Security No.
12. PREVIOUS ADDRESS IF UPDATING CURRENT REGISTRATION - Previous House Number and Street
Previous City or Post Ofce
County State
13. CHANGE OF NAME ONLY Former Legal Name Former Signature
14.
FOR BOARD
USE ONLY
SEC4010 (Rev. 6/12)
City, Village, Twp.
Ward
Precinct
School Dist.
Cong. Dist.
Senate Dist.
House Dist.
(one form of ID required to be listed or provided)
Registering as an Ohio voter
Updating my address
Updating my name
I am:
I declare under penalty of
election falsication I am a
citizen of the United States, will
have lived in this state for 30
days immediately preceding
the next election, and will be
at least 18 years of age at the
time of the general election.
Your Signature
Date_______/_______/_______
MO DAY YR
Ohio Driver’s License No. OR
Last Four Digits of Social Security No.
(one form of ID required to be listed or provided)
