Application for Absent Voter’s Ballots                         
                                    PLEASE PRINT OR TYPE

MUST BE FULLY COMPLETED                          Send Ballot to:

                                                                                                                (if different from home address)

Voter’s Name____________________________________  Name_________________________________________

Home Address___________________________________   Care of/PO Box_________________________________

City, Village, or Post 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________________________, or

                        The last four digits of your social security number_________________, or

                        A copy of a current and valid photo identification, a current utility bill, bank statement,
                        government check, paycheck or other government document that shows your name
                        and current address.

I wish to vote in the General Election to be held on November 6, 2012.                                                  

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 10

days after the election.

            I hereby declare, under penalty of election falsification, I am a qualified voter 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

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 _____________________________