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 as follows:

"Provisional Ballot Affirmation

(A) Clearly print your full name: ...................

(B) Write your date of birth: .......................

(C)

(1) Write your current address: ..................

.....................................................

(2) Have you moved without updating your voter registration?: Yes ...... No ......

If yes, write your former address: ..........................

.....................................................

Failure to provide your former address will not cause your provisional ballot to be rejected.

(D) Provide one of the following forms of identification:

(1) Write your full Ohio driver's license or state identification card number: ........................

(2) Write the last four digits of your Social Security number: ...............

(3) If you did not write your full Ohio driver's license or state identification card number or the last four digits of your Social Security number, you must show one of the following forms of identification to the precinct election official. If you do not check one of the following boxes affirming the type of identification you showed to the precinct election official, the board of elections will conclude that you did not show identification to your precinct election official and that you must show identification at the board of elections during the seven days after the election for your vote to be eligible to be counted.

...... A form of 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;

...... A military identification card; or

...... A current 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.

(4) If you fail to provide identification at this time, you must go to the board of elections on or before the seventh day following this election to provide a qualifying form of identification in order for this ballot to count.

(E) If your right to vote has been challenged, you must provide any required additional information to the board of elections on or before the seventh day following this election.

(F) Sign and date the following statement:

I solemnly swear or affirm that I am a citizen of the United States; that I will be at least 18 years of age at the time of the general election; that I have lived in this state for 30 days immediately preceding this election in which I am voting this ballot; that I am a registered voter in the precinct 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 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 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

Date

WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.

"

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 provided all of the information required under section 3503.14 of the Revised Code to register to vote or to update the individual's registration on the provisional ballot affirmation, the board of elections shall consider the individual's provisional ballot affirmation to also serve as a notice of change of name, change of residence, or both, or as a voter registration form, as applicable, for that individual only for the purposes of future elections.

Amended by 130th General Assembly File No. 67, SB 216, §1, eff. 6/1/2014.

Amended by 130th General Assembly File No. 3, SB 47, §1, eff. 6/21/2013.

Amended by 129th General AssemblyFile No.105, SB 295, §1, eff. 8/15/2012.

Amended by 129th General AssemblyFile No.40, HB 194, §1 Made subject to referendum in the Nov. 6, 2012 election. The version of this section thus amended was repealed by 129th General AssemblyFile No.105, SB 295, §1, eff. 8/15/2012.

Effective Date: 05-02-2006; 2008 HB562 09-22-2008