Each individual who casts a provisional ballot under section 3505.181 of the Revised Code shall execute a written affirmation. The form of the written affirmation shall be printed upon the face of the provisional ballot envelope and shall be substantially as follows:
“Provisional Ballot Affirmation
STATE OF OHIO
I, .................... (Name of provisional voter), solemnly swear or affirm that I am a registered voter in the jurisdiction in which I am voting this provisional ballot and that I am eligible to vote in the election in which I am voting this provisional ballot.
I understand that, if the above-provided information 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 further 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 of Voter)
..............................
(Voter’s date of birth)
The last four digits of the voter’s social security number
..............................
(To be provided if the voter is unable to provide a current and valid photo identification, a military identification , or a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, that shows the voter’s name and current address but is able to provide these last four digits)
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.
Additional Information For Determining Ballot Validity
(May be completed at voter’s discretion)
Voter’s current address:
...........................
Voter’s former address if photo identification does not contain voter’s current address
Voter’s driver’s license number or, if not provided above, the last four digits of voter’s social security number
...........................
(Please circle number type)
(Voter may attach a copy of any of the following for identification purposes: a current and valid photo identification, a military identification , or a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, that shows the voter’s name and current address.)
Reason for voting provisional ballot (Check one):
..... Requested, but did not receive, absent voter’s ballot
..... Other
Verification Statement
(To be completed by election official)
The Provisional Ballot Affirmation printed above was subscribed and affirmed before me this …....... day of …....... (Month), .......... (Year).
(If applicable, the election official must check the following true statement concerning additional information needed to determine the eligibility of the provisional voter.)
...... The provisional voter is required to provide additional information to the board of elections.
...... An application or challenge hearing regarding this voter has been postponed until after the election.
(The election official must check the following true statement concerning identification provided by the provisional voter, if any.)
...... The provisional voter provided a current and valid photo identification.
...... The provisional voter provided a current valid photo identification, other than a driver’s license or a state identification card, with the voter’s former address instead of current address and has provided the election official both the current and former addresses.
...... The provisional voter provided a military identification or a copy of a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, with the voter’s name and current address.
...... The provisional voter provided the last four digits of the voter’s social security number.
...... The provisional voter is not able to provide a current and valid photo identification, a military identification , or a copy of a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, with the voter’s name and current address but does have one of these forms of identification. The provisional voter must provide one of the foregoing items of identification to the board of elections within ten days after the election.
..... The provisional voter is not able to provide a current and valid photo identification, a military identification , or a copy of a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, with the voter’s name and current address but does have one of these forms of identification. Additionally, the provisional voter does have a social security number but is not able to provide the last four digits of the voter’s social security number before voting. The provisional voter must provide one of the foregoing items of identification or the last four digits of the voter’s social security number to the board of elections within ten days after the election.
..... The provisional voter does not have a current and valid photo identification, a military identification , a copy of a current utility bill, bank statement, government check, paycheck, or other government document with the voter’s name and current address, or a social security number, but has executed an affirmation.
..... The provisional voter does not have a current and valid photo identification, a military identification , a copy of a current utility bill, bank statement, government check, paycheck, or other government document with the voter’s name and current address, or a social security number, and has declined to execute an affirmation.
..... The provisional voter declined to provide a current and valid photo identification, a military identification , a copy of a current utility bill, bank statement, government check, paycheck, or other government document with the voter’s name and current address, or the last four digits of the voter’s social security number but does have one of these forms of identification or a social security number. The provisional voter must provide one of the foregoing items of identification or the last four digits of the voter’s social security number to the board of elections within ten days after the election.
(Signature of Election Official)”
In addition to any information required to be included on the written affirmation, an individual casting a provisional ballot may provide additional information to the election official to assist the board of elections in determining the individual’s eligibility to vote in that election, including the date and location at which the individual registered to vote, if known.
If the individual declines to execute the affirmation, an appropriate local election official shall comply with division (B)(6) of section 3505.181 of the Revised Code.
Each individual who casts a provisional ballot under section 3505.181 of the Revised Code shall execute a written affirmation. The form of the written affirmation shall be printed upon the face of the provisional ballot envelope and shall be substantially as follows:
“Provisional Ballot Affirmation
STATE OF OHIO
I, .................... (Name of provisional voter), solemnly swear or affirm that I am a registered voter in the jurisdiction in which I am voting this provisional ballot and that I am eligible to vote in the election in which I am voting this provisional ballot.
I understand that, if the above-provided information 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 further 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 of Voter)
..............................
(Voter’s date of birth)
The last four digits of the voter’s social security number
..............................
(To be provided if the voter is unable to provide a current and valid photo identification, a military identification , or a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, that shows the voter’s name and current address but is able to provide these last four digits)
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.
Additional Information For Determining Ballot Validity
(May be completed at voter’s discretion)
Voter’s current address:
...........................
Voter’s former address if photo identification does not contain voter’s current address
Voter’s driver’s license number or, if not provided above, the last four digits of voter’s social security number
...........................
(Please circle number type)
(Voter may attach a copy of any of the following for identification purposes: a current and valid photo identification, a military identification , or a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, that shows the voter’s name and current address.)
Reason for voting provisional ballot (Check one):
..... Requested, but did not receive, absent voter’s ballot
..... Other
Verification Statement
(To be completed by election official)
The Provisional Ballot Affirmation printed above was subscribed and affirmed before me this …....... day of …....... (Month), .......... (Year).
(If applicable, the election official must check the following true statement concerning additional information needed to determine the eligibility of the provisional voter.)
...... The provisional voter is required to provide additional information to the board of elections.
...... An application or challenge hearing regarding this voter has been postponed until after the election.
(The election official must check the following true statement concerning identification provided by the provisional voter, if any.)
...... The provisional voter provided a current and valid photo identification.
...... The provisional voter provided a current valid photo identification, other than a driver’s license or a state identification card, with the voter’s former address instead of current address and has provided the election official both the current and former addresses.
...... The provisional voter provided a military identification or a copy of a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, with the voter’s name and current address.
...... The provisional voter provided the last four digits of the voter’s social security number.
...... The provisional voter is not able to provide a current and valid photo identification, a military identification , or a copy of a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, with the voter’s name and current address but does have one of these forms of identification. The provisional voter must provide one of the foregoing items of identification to the board of elections within ten days after the election.
..... The provisional voter is not able to provide a current and valid photo identification, a military identification , or a copy of a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, with the voter’s name and current address but does have one of these forms of identification. Additionally, the provisional voter does have a social security number but is not able to provide the last four digits of the voter’s social security number before voting. The provisional voter must provide one of the foregoing items of identification or the last four digits of the voter’s social security number to the board of elections within ten days after the election.
..... The provisional voter does not have a current and valid photo identification, a military identification , a copy of a current utility bill, bank statement, government check, paycheck, or other government document with the voter’s name and current address, or a social security number, but has executed an affirmation.
..... The provisional voter does not have a current and valid photo identification, a military identification , a copy of a current utility bill, bank statement, government check, paycheck, or other government document with the voter’s name and current address, or a social security number, and has declined to execute an affirmation.
..... The provisional voter declined to provide a current and valid photo identification, a military identification , a copy of a current utility bill, bank statement, government check, paycheck, or other government document with the voter’s name and current address, or the last four digits of the voter’s social security number but does have one of these forms of identification or a social security number. The provisional voter must provide one of the foregoing items of identification or the last four digits of the voter’s social security number to the board of elections within ten days after the election.
(Signature of Election Official)”
In addition to any information required to be included on the written affirmation, an individual casting a provisional ballot may provide additional information to the election official to assist the board of elections in determining the individual’s eligibility to vote in that election, including the date and location at which the individual registered to vote, if known.
If the individual declines to execute the affirmation, an appropriate local election official shall comply with division (B)(6) of section 3505.181 of the Revised Code.
Each individual who casts a provisional ballot under section 3505.181 of the Revised Code shall execute a written affirmation. The form of the written affirmation shall be printed upon the face of the provisional ballot envelope and shall be substantially as follows:
“Provisional Ballot Affirmation
STATE OF OHIO
I, .................... (Name of provisional voter), solemnly swear or affirm that I am a registered voter in the jurisdiction in which I am voting this provisional ballot and that I am eligible to vote in the election in which I am voting this provisional ballot.
I understand that, if the above-provided information 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 further 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 of Voter)
..............................
(Voter’s date of birth)
The last four digits of the voter’s social security number
..............................
(To be provided if the voter is unable to provide a current and valid photo identification, a military identification , or a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, that shows the voter’s name and current address but is able to provide these last four digits)
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.
Additional Information For Determining Ballot Validity
(May be completed at voter’s discretion)
Voter’s current address:
...........................
Voter’s former address if photo identification does not contain voter’s current address
Voter’s driver’s license number or, if not provided above, the last four digits of voter’s social security number
...........................
(Please circle number type)
(Voter may attach a copy of any of the following for identification purposes: a current and valid photo identification, a military identification , or a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, that shows the voter’s name and current address.)
Reason for voting provisional ballot (Check one):
..... Requested, but did not receive, absent voter’s ballot
..... Other
Verification Statement
(To be completed by election official)
The Provisional Ballot Affirmation printed above was subscribed and affirmed before me this …....... day of …....... (Month), .......... (Year).
(If applicable, the election official must check the following true statement concerning additional information needed to determine the eligibility of the provisional voter.)
...... The provisional voter is required to provide additional information to the board of elections.
...... An application or challenge hearing regarding this voter has been postponed until after the election.
(The election official must check the following true statement concerning identification provided by the provisional voter, if any.)
...... The provisional voter provided a current and valid photo identification.
...... The provisional voter provided a current valid photo identification, other than a driver’s license or a state identification card, with the voter’s former address instead of current address and has provided the election official both the current and former addresses.
...... The provisional voter provided a military identification or a copy of a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, with the voter’s name and current address.
...... The provisional voter provided the last four digits of the voter’s social security number.
...... The provisional voter is not able to provide a current and valid photo identification, a military identification , or a copy of a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, with the voter’s name and current address but does have one of these forms of identification. The provisional voter must provide one of the foregoing items of identification to the board of elections within ten days after the election.
..... The provisional voter is not able to provide a current and valid photo identification, a military identification , or a copy of a current utility bill, bank statement, government check, paycheck, or other government document, other than a notice of an election mailed by a board of elections under section 3501.19 of the Revised Code or a notice of voter registration mailed by a board of elections under section 3503.19 of the Revised Code, with the voter’s name and current address but does have one of these forms of identification. Additionally, the provisional voter does have a social security number but is not able to provide the last four digits of the voter’s social security number before voting. The provisional voter must provide one of the foregoing items of identification or the last four digits of the voter’s social security number to the board of elections within ten days after the election.
..... The provisional voter does not have a current and valid photo identification, a military identification , a copy of a current utility bill, bank statement, government check, paycheck, or other government document with the voter’s name and current address, or a social security number, but has executed an affirmation.
..... The provisional voter does not have a current and valid photo identification, a military identification , a copy of a current utility bill, bank statement, government check, paycheck, or other government document with the voter’s name and current address, or a social security number, and has declined to execute an affirmation.
..... The provisional voter declined to provide a current and valid photo identification, a military identification , a copy of a current utility bill, bank statement, government check, paycheck, or other government document with the voter’s name and current address, or the last four digits of the voter’s social security number but does have one of these forms of identification or a social security number. The provisional voter must provide one of the foregoing items of identification or the last four digits of the voter’s social security number to the board of elections within ten days after the election.
(Signature of Election Official)”
In addition to any information required to be included on the written affirmation, an individual casting a provisional ballot may provide additional information to the election official to assist the board of elections in determining the individual’s eligibility to vote in that election, including the date and location at which the individual registered to vote, if known.
If the individual declines to execute the affirmation, an appropriate local election official shall comply with division (B)(6) of section 3505.181 of the Revised Code.
