§ 17-20-13 - Form of application.
SECTION 17-20-13
§ 17-20-13 Form of application. – The application to be subscribed by the voters before receiving a mail ballotshall, in addition to those directions that may be printed, stamped, or writtenon it by authority of the secretary of state, be in substantially the followingform:
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONSAPPLICATION OF VOTER FOR BALLOT FOR ELECTION ON]]]]]]]]
=hd15 (COMPLETE HIGHLIGHTED SECTIONS)
=hd16 NOTE – THIS APPLICATION MUST BE RECEIVED BYTHE BOARD OF CANVASSERS OF YOUR CITY OR TOWN NOT LATER THAN 4:00 P.MON]]]]]]]]
BOX A (PRINT OR TYPE)
NAME
VOTING ADDRESS
CITY/TOWNSTATE RI ZIPCODE]]]]]]]]]]]]
DATE OF BIRTHPHONE #]]]]]]]]]]]]]]]]]]
BOX B (PRINT OR TYPE)
NAME OF INSTITUTION (IF APPLICABLE)
ADDRESS
ADDRESS
CITY/TOWN]]]]]]]] STATE]]]]]]]] ZIP CODE]]]]]]]]
FACSIMILE NUMBER (if applicable)
I CERTIFY THAT I AM ELIGIBLE FOR A MAIL BALLOT ON THEFOLLOWING BASIS; (CHECK ONE ONLY)
( ) 1. I will be absent from thestate on the date of the election during the entire period of time when thepolls are to be open. Provide an out-of-state mailing address in BOX B above orthe ballot will be mailed to the local board of canvassers.
( ) 2. I will be absent from thecity or town of my voting residence during the entire period of time when thepolls are to be open because of my status as a student, or spouse of a student,at an institution of higher learning within the state of Rhode Island.
Complete BOX B above with your entire address or the ballotwill be mailed to the address in BOX A.
Indicate name of institution]]]]]]]]
( ) 3. I am incapacitated tosuch an extent that it would be an undue hardship to vote at the polls becauseof illness, mental or physical disability, blindness or a serious impairment ofmobility. Ballot will be mailed to address in BOX A.
( ) 4. I belong to a religionwhose tenets forbid secular activity, including voting, on the day of election.Ballot will be mailed to address in BOX A.
( ) 5. I am confined in ahospital, convalescent home, nursing home, rest home, or similar institution.Complete BOX B above.
( ) 6. I am detained whileawaiting trial or imprisoned for a cause other than final conviction of afelony. Complete BOX B above.
( ) 7. I am employed or inservice intimately connected with military operations or because I am a spouseor dependent of such person. Complete BOX B above or the ballot will be mailedto the local board of canvassers.
( ) 8. I am employed by the(a)( ) state board of elections,(b)( ) elections division of the secretary ofstate, (c)( ) a member of the staff of a localcanvassing authority, (d)( ) or a poll workerassigned to work election day outside of their voting district.
I declare that all of the information I have provided on thisform is true and correct to the best of my knowledge. I further state that I amnot a qualified voter of any other city or town or state and have not claimedand do not intend to claim the right to vote in any other city or town or state.
If unable to sign name because of physical incapacity orotherwise, applicant shall make his or her mark "X".
SIGNATURE IN FULL]]]]]]]]
This application must either be sworn to before a notarypublic OR before two (2) witnesses who must sign their names and affix theiraddresses. No witness or notary is necessary if checking category No. 7.
WITNESSES:
Name
Address
Name
Address
OR
NOTARY:
(If executed outside of RI by a notary public, attest inmanner authorized by law of places where taken.)
Sworn to (or affirmed) before me, this]]]]]]]] dayof]]]]]]]]]]]]]], 20]]]] .
Notary Public
My Commission Expires: ]]]]]]]]]]]]]]]]]]