Form No. 11-B Prescribed by the Secretary of State (08-17)
Absentee Ballot Application
IN-COUNTY or OUT-OF-COUNTY Non-ADA Hospitalization Due to an
Accident or Unforeseeable Medical Emergency That Occurred After 12:00 p.m. (noon)
on the Saturday Before Election Day and Before 3:00 p.m. on Election Day
print clearly
R.C. 3509.08(B)
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
Reason
Required
Select only ONE.
4
I am confined in the hospital listed below as a result of an accident or unforeseeable medical emergency; OR
My minor child is confined in the hospital listed below as a result of an accident or unforeseeable medical emergency.
Please Deliver my
Ballot as Follows
Required
Select only ONE.
*
"Family member" means the
voter's: spouse, father, mother,
father-in-law, mother-in-law,
grandfather, grandmother, brother,
sister, son, daughter, stepparent,
stepchild, uncle, aunt, nephew or
niece.
5
Hospital located in my county of residence:
I request that two election officials deliver my ballot to me at the hospital named below; OR
I request that the family member named below deliver my ballot to me at the hospital.
Name of family member Relationship to Voter*
Hospital located outside my county of residence (If you have a disability under the ADA, use form 11-B-2):
I request that the family member named below deliver my ballot to me at the hospital; OR
Name of family member Relationship to Voter*
I request to receive the ballot by mail at the hospital.
Hospital
Information /
Where to Deliver
Ballot
Required
6
Name of Hospital Room #
Admission Date
County
Hospital Street Address ZIP
City/Village Phone
Identification
Required
You must provide ONE of the
following.
7
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.
8
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
9
• I wish to receive an absentee ballot via the method marked above.
• I understand this request must be received by my board of elections no later than 3 p.m. on Election Day.
• I understand that if an absentee ballot is mailed or delivered 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.
