Form 11-B "Absentee Ballot Application - in-County or out-Of-County Non-ada Hospitalization Due to an Accident or Unforeseeable Medical Emergency" - Ohio

What Is Form 11-B?

This is a legal form that was released by the Ohio Secretary of State - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the Ohio Secretary of State;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form 11-B by clicking the link below or browse more documents and templates provided by the Ohio Secretary of State.

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Download Form 11-B "Absentee Ballot Application - in-County or out-Of-County Non-ada Hospitalization Due to an Accident or Unforeseeable Medical Emergency" - Ohio

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Form No. 11-B Prescribed by the Secretary of State (08-17)
Absentee Ballot Application
print clearly
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
R.C. 3509.08(B)
Voter Name
First
Middle
1
Required
Last
Suffix
Date of Birth
2
Date of Birth
MM/DD/YYYY
(Do not write today's date here)
Required
Address at Which
Street Address
County
(No P.O. Boxes)
you are Registered
3
to Vote
City/Village
ZIP
Required
Reason
I am confined in the hospital listed below as a result of an accident or unforeseeable medical emergency; OR
4
Required
My minor child is confined in the hospital listed below as a result of an accident or unforeseeable medical emergency.
Select only ONE.
Hospital located in my county of residence:
Please Deliver my
I request that two election officials deliver my ballot to me at the hospital named below; OR
Ballot as Follows
I request that the family member named below deliver my ballot to me at the hospital.
Required
Select only ONE.
Name of family member
Relationship to Voter*
"Family member" means the
*
5
voter's: spouse, father, mother,
Hospital located outside my county of residence (If you have a disability under the ADA, use form 11-B-2):
father-in-law, mother-in-law,
grandfather, grandmother, brother,
I request that the family member named below deliver my ballot to me at the hospital; OR
sister, son, daughter, stepparent,
stepchild, uncle, aunt, nephew or
Name of family member
Relationship to Voter*
niece.
I request to receive the ballot by mail at the hospital.
Hospital
Name of Hospital
Room #
Information /
Where to Deliver
County
Admission Date
6
Ballot
Hospital Street Address
ZIP
Required
City/Village
Phone
Identification
OR
Your Ohio driver’s license number
(2 letters followed by 6 numbers)
Required
Last four digits of your Social Security number
7
OR
You must provide ONE of the
Copy of a current and valid photo identification, military identification, or a current (within the last 12 months) utility bill,
following.
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
Date of Election
MM/DD/YYYY
(Do not write today's date here)
Required
General Election
Special Election
8
You must complete a separate
Primary Election
For a PARTISAN primary election only, you must choose the type of ballot:
application for each election.
Political party ballot
Issues only ballot
Name of Political Party
Affirmation
• 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.
Required
• 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.
9
• 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
MM/DD/YYYY
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.
Form No. 11-B Prescribed by the Secretary of State (08-17)
Absentee Ballot Application
print clearly
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
R.C. 3509.08(B)
Voter Name
First
Middle
1
Required
Last
Suffix
Date of Birth
2
Date of Birth
MM/DD/YYYY
(Do not write today's date here)
Required
Address at Which
Street Address
County
(No P.O. Boxes)
you are Registered
3
to Vote
City/Village
ZIP
Required
Reason
I am confined in the hospital listed below as a result of an accident or unforeseeable medical emergency; OR
4
Required
My minor child is confined in the hospital listed below as a result of an accident or unforeseeable medical emergency.
Select only ONE.
Hospital located in my county of residence:
Please Deliver my
I request that two election officials deliver my ballot to me at the hospital named below; OR
Ballot as Follows
I request that the family member named below deliver my ballot to me at the hospital.
Required
Select only ONE.
Name of family member
Relationship to Voter*
"Family member" means the
*
5
voter's: spouse, father, mother,
Hospital located outside my county of residence (If you have a disability under the ADA, use form 11-B-2):
father-in-law, mother-in-law,
grandfather, grandmother, brother,
I request that the family member named below deliver my ballot to me at the hospital; OR
sister, son, daughter, stepparent,
stepchild, uncle, aunt, nephew or
Name of family member
Relationship to Voter*
niece.
I request to receive the ballot by mail at the hospital.
Hospital
Name of Hospital
Room #
Information /
Where to Deliver
County
Admission Date
6
Ballot
Hospital Street Address
ZIP
Required
City/Village
Phone
Identification
OR
Your Ohio driver’s license number
(2 letters followed by 6 numbers)
Required
Last four digits of your Social Security number
7
OR
You must provide ONE of the
Copy of a current and valid photo identification, military identification, or a current (within the last 12 months) utility bill,
following.
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
Date of Election
MM/DD/YYYY
(Do not write today's date here)
Required
General Election
Special Election
8
You must complete a separate
Primary Election
For a PARTISAN primary election only, you must choose the type of ballot:
application for each election.
Political party ballot
Issues only ballot
Name of Political Party
Affirmation
• 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.
Required
• 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.
9
• 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
MM/DD/YYYY
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.