FOR OFFICE USE ONLY
PRECINCT NAME    
 		VILLAGE
SCHOOL
DISTRICT
 		FIRE
DISTRICT      




APPLICATION #
BALLOT #
                  

Application for Absent Voter's Ballots
PLEASE TYPE OR PRINT
* FOR VOTERS REGISTERED IN PUTNAM COUNTY, RETURN COMPLETED FORM TO:
Putnam County Board of Elections  
Annex Building
336 East Main Street
Ottawa, Ohio 45875
419-523-3343
Please print this form out and mail it to the address above: 

Applicant's Name ____________________________________

Home Address _______________________________________

City, Village, or Post Office ____________________________

County ____________ Zip Code _________________________

You must provide your birthdate:
month        /       day/         year and one of the following:                                                                                                   
   *Your  Ohio driver's license number_______________,or
   *The last four digits of your social security number _______________, or
   *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 address.

*** I here by 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.

 Send Ballots to: (if different from home address)

Name___________________________________________

Care of/P.O. Box __________________________________

Address _________________________________________

City _________ State _____ Zip Code ______

I wish to vote in the following election:
(check one)

1.  Primary Election
    o Democratic
    o Republican
    o Nonpartisan or issues only
    o Other Party (specify)  ______________

2. o General Election

3. o Special Election
Date of Election __________________
X________________________________________________
Signature of Applicant		 ____________
Date

INSTRUCTIONS

Chapter 3509 of  the Revised Code of Ohio

1 .  Use of this form is optional.  To be valid, an application must include the voter's name, voting residence address, date of birth, and signature; the election for which the ballot is requested and, if a partisan primary election, the voter's political party affiliation; and one of the following: voter's Ohio drivers license number, the last four digits of the voter's social security number, or a copy of the voter's current and valid photo identification or a copy of a current utility bill, bank statement, government check, paycheck or other government document that shows the voter's name and address.
2.  An application by mail must be received by your county board of elections by noon on the third day before the election.  Applications by the voter in person must be received by the close of regular board office hours the day before the election.  Applications for persons who are hospitalized due to a medical emergency will be accepted until 3 p.m. on election day.
3.  Your completed ballot must be delivered to your county board of elections office in person by you or a near relative, or by mail not later than the close of polls on election day.  Exception:  If the voter is outside of the United States on election day, the ballot envelope must be signed or postmarked prior to the close of polls and received by the board no later than 10 days after the election or 20 days after the presidential primary election.
4.  This document may be reproduced.