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R.C. 3503.16; 3505.18; .181; .182; .183.
Form No. 12-B Prescribed by the Secretary of State (08-17)
Provisional Ballot Affirmation
ZIP
City/Village
Street Address (No P.O. Boxes)
3
Current Ohio
Address
Required
Date of Birth (Do not write today's date here)
2
Date of Birth
Required
SuffixLast
MiddleFirst
1
Full Name
Required
ZIPCity/Village
Street Address (No P.O. Boxes)
4
Former Address
Not Required
If you do not provide your former
address it will not cause your ballot
to be rejected.
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
Identification
Required
Do ONE of the following:
• Write your full Ohio driver’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.
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.
Last four digits of your Social Security number
Your Ohio driver’s license number or state identification card number (2 letters followed by 6 numbers)
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.
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.
Affirmation
Required
Today's Date
Signature X
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.
Military identification Card
County
State
MM/DD/YYYY
MM/DD/YYYY
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