Form No. 11-A Prescribed by the Secretary of State (06-14)
APPLICATION FOR ABSENT VOTER’S BALLOT
PLEASE PRINT OR TYPE (See Instructions at Bottom of Page) R.C. 3509.03
Summit County Board of Elections
470 Grant Street Phone: (330) 643-5200
Akron, Ohio 44311-1157 www.summitcountyboe.com
Send Ballot to: (if different from home address)
Voter’s Name ______________________________________ Name ___________________________________________
Home Address _____________________________________ care of/PO Box ____________________________________
City, Village, Office _________________________________ Address __________________________________________
County ____________________Zip Code _______________ City__________________ State______ Zip Code_________
You must provide your birth date: ___________/__________/__________ and ONE of the following:
(month) (day) (year)
Your Ohio driver’s license number (begins with two letters followed by six numbers) ____________________, or
The last four digits of your Social Security number ____________________, or
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 notice of
voter registration mailed by a board of elections) that shows your name and current address.
I wish to vote in the election to be held on _______________________________.
(month-date-year of election)
Check ONLY one election (A separate application must be completed for each election):
1. Primary Election
(If you checked primary election, select the type of ballot):
Party Issues only
(Name of political party)
2. General Election
3. 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 11 days after the election.
I hereby declare, under penalty of election falsification, I am a qualified elector 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.
Applications for persons who are hospitalized or for persons whose minor child is hospitalized due to an accident or unforeseeable
medical emergency (Form 11-B) will be accepted until 3 p.m. on Election Day.
2. If you return your ballot by mail, it must be received by your board of elections by 7:30 p.m. on Election Day or postmarked* no
later than the day before Election Day and received by your county board of elections no later than 10 days after the electio n. If you
return your ballot in person, or if a near relative delivers it to the board for you, it must be received by your county board of elections
no later than the close of polls on Election Day. If you are a member of the uniformed services or a voter outside of the United States
on Election Day, the ballot must be submitted for mailing not later than 12:01 a.m. on the date of the election and received by the
board no later than 10 days after Election Day.
*Postmarked does not include a date marked by a postage evidence system such as a postage meter.
