Form 11-A Prescribed by the Ohio Secretary of State (7/2020)
please print clearlyR.C. 3509.03
Absentee Ballot Application
Email:Telephone Number:
2) Your contact information
(recommended)
Contact information will be used by the board of elections to contact you in a timely manner if your application is incomplete.
Suffix:
Last:
Middle:First:
1) Your name
ZIP:State:County:City:
Street Address:
4) Your home address at which you are registered to vote
(no P.O. Boxes or polling place addresses)
8) Affirmation
• I understand that, per Ohio law, the board of elections must receive this request no later than noon on the Saturday
before Election Day. To account for possible delivery delay, return the application to the board of elections at least seven
days before the election.
• 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.
• I understand that if I do not provide the board with all of 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.
Important: If selecting a partisan ballot in a primary election, the ballot will include all questions and issues which the voter is eligible to vote.
Democratic Libertarian Republican Issues Only
If a primary election is selected, indicate the type of ballot you would like to receive by selecting ONE of the following:
Date:
Date:
November General Election
Special Election
Primary Election
7) Election in which you would like to vote (you must complete a separate application for each election)
C. A 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.
6) Your identification
Provide ONE of the following:
ZIP:State:City:
Street Address (or P.O. Box):
5) The address where you receive mail
(if different than above)
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.
9) I am interested in serving as a poll worker on Election Day. (optional)
NoYes
/ /
/ /
/ /
3) Your date of birth:
A. Write in the last four digits of your Social Security number:
B. Write in your Ohio driver license number
(2 letters followed by 6 numbers):
/ /
Today's Date:
Signature X
