Form No. 12-B Prescribed by the Secretary of State
(06/03/2014)
Provisional Ballot Affirmation
R.C. 3503.16; 3505.18; .181; .182; .183.
Full Name
Required
Print clearly.
1
First name Middle Name
Last name Suffix
Example: Sr., Jr., III, etc.
Date of Birth
Required
2
Date of Birth …….………………………..………………………….
M M D D Y Y Y Y
Current Ohio address
Required
3
Street address (not P.O. Box)
City / Village
ZIP
Former address
Not required
If you do not provide your former
address it will not cause your
ballot to be rejected.
4
If you do not complete this step, it will not cause your ballot to be rejected.
Have you moved without updating your voter registration? …………..…. YES NO
Street address (not P.O. Box)
City / Village
State ZIP
Identification
Required
Do ONE of the following:
• Wri
te your full Ohio
d
ri
v
e
r’
s
license or state
identification card
number, or
• Write the last four digits
of your Social Security
number, or
• Check the box next to
the form of identification
you showed to the
precinct
election official.
5
If you do not provide identification at this time, you must go to the board of elections on or before the
7th day after this election to provide a qualifying form of identification.
Your Ohio driver’s license number or
2 letters followed by 6 numbers
state identification card number…………………………..
Last four digits of your Social Security number ………………………………….
Military identification card ……………………………………………………………………………..……….
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
…………………………..
Photo identification that was issued by the United States government or the State of
Ohio, that contains your name and current address (or your former address if the
identification is an Ohio driver’s license or state identification card), and that has an
expiration date that has not passed ……………………………………………………………………..…
Affirmation
Required
6
I solemnly swear or affirm, under penalty of election falsification, that:
• I am a citizen of the United States and will be at least 18 years of age at the time of the general election.
• I have lived in this state for 30 days immediately preceding this election in which I am voting this ballot.
• I am a registered voter in the precinct in which I am voting this provisional ballot.
• I am eligible to vote in the election in which I am voting this provisional ballot.
• I understand that, if the information I provide on this provisional ballot affirmation is not fully completed and correct, if the board
of elections determines that I am not registered to vote, a resident of this precinct, or eligible to vote in this election, or if the
board of elections determines that I have already voted in this election, my provisional ballot will not be counted.
• I understand that, if I am not currently registered to vote or if I am not registered at my current address or under my current
name, this form will serve as an application to register to vote or update my registration for future elections, as long as I provide all
of the information required to register to vote or update my registration.
• I understand that knowingly providing false information is a violation of law and subjects me to possible criminal prosecution.
• I hereby declare, under penalty of election falsification, that the above statements are true and correct to the best of my
knowledge and belief.
Signature X
Today’s date
M M D D Y Y Y Y
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.
