Form No. 11-A Prescribed by the Secretary of State (08-17)
Absentee Ballot Application
Date of Birth
Date of Birth (do not write today's date here)
Address at Which
you are Registered
Street Address (no P.O. boxes)
Required only if you wish to
have your ballot mailed to a
different address than the
address at which you're
registered to vote.
Street Address (or P.O. box)
You must provide ONE of the
Your Ohio driver license number (2 letters followed by 6 numbers)
Last four digits of your Social Security number
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.
You must complete a separate
application for each election.
Date of Election (do not write today's date here)
For a PARTISAN primary election only, you must choose the type of ballot:
Political party ballot
Name of Political Party
Issues only ballot
• 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
• I hereby declare, under penalty of election falsification, that I am a qualified elector and
the statements above are true.
To assist the board of election in contacting you in a timely manner if your application is incomplete, please provide the following information.
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.