2009 Rhode Island Code
Title 17 - Elections
CHAPTER 17-20 - Mail Ballots
§ 17-20-13.1 - Form of Emergency Mail Ballot Application.

SECTION 17-20-13.1

   § 17-20-13.1  Form of Emergency Mail Ballot Application. – The emergency mail ballot application to be subscribed by the voters before receiving a mail ballot shall, in addition to any directions that may be printed, stamped, or written on the application by authority of the secretary of state, be in substantially the following form:

   STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS EMERGENCY APPLICATION OF VOTER FOR BALLOT FOR ELECTION ON]]]]]]]]

   =hd15 (COMPLETE HIGHLIGHTED SECTIONS)

   =hd16 NOTE – THIS APPLICATION MUST BE RECEIVED BY THE BOARD OF CANVASSERS OF YOUR CITY OR TOWN NOT LATER THAN 4:00 P.M. ON]]]]]]]]

   BOX A (PRINT OR TYPE)

   NAME

   VOTING ADDRESS

   CITY/TOWNSTATE    RI   ZIP CODE]]]]]]]]]]]]

   DATE OF BIRTHPHONE#]]]]]]]]]]]]]]              &n bsp;       

   BOX B (PRINT OR TYPE)

   NAME OF INSTITUTION (IF APPLICABLE)

   ADDRESS

   ADDRESS

   CITY/TOWNSTATE]]]]]]]] ZIP CODE]]]]]]]]]]]]              &n bsp;       

   I CERTIFY THAT I AM ELIGIBLE FOR A MAIL BALLOT ON THE FOLLOWING BASIS: (CHECK ONE ONLY)

   (     ) 1.  I will be absent from the state on the day of the election during the entire period of time when the polls are to be open. If not voting ballot at local board, provide an out of state mailing address in BOX B above.

   (     ) 2.  I will be absent from the city or town of my voting residence during the entire period of time when the polls 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. If not voting ballot at local board, provide address in BOX B above. Indicate name of institution.

   (     ) 3.  I am incapacitated to such an extent that it would be an undue hardship to vote at the polls because of illness, mental or physical disability, blindness or a serious impairment of mobility. Medical form R-50 must be completed. If not voting ballot at local board, ballot will be delivered to address in BOX A above.

   (     ) 4.  I belong to a religion whose tenets forbid secular activity, including voting, on the day of election. If not voting ballot at local board, ballot will be delivered to address in BOX A above.

   (     ) 5.  I am confined in a hospital, convalescent home, nursing home, rest home, or similar institution. Complete BOX B above.

   (     ) 6.  I am detained while awaiting trial or imprisoned for a cause other than final conviction of a felony. Complete BOX B above.

   (     ) 7.  I am employed or in service intimately connected with military operations or because I am a spouse or dependent of such person. If not voting ballot at local board, provide address in BOX B above.

   (     ) 8.  I am employed by the state board of elections, elections division of the secretary of state, a member of the staff of a local canvassing authority, or a poll worker assigned to work Election Day outside of their voting district.

   Under the pains and penalty of perjury, I certify that on account of the following circumstances manifested twenty (20) days or less prior to the election for which I make this application. I will be unable to vote at the polls.

   Circumstances necessitating mail ballot: (Please describe below if checking category 1, 2, 4, 5, 6, 7 or 8)

   I declare that all of the information I have provided on this form is true and correct to the best of my knowledge. I further state that I am not a qualified voter of any other city or town or state and have not claimed and 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 or otherwise, applicant shall make his or her mark "X".

   SIGNATURE IN FULL

   This application must either be sworn to before a notary public OR before two (2) witnesses who must sign their names and affix their addresses. No witness or notary is necessary if checking category #7.

   WITNESSES:

   Name         &nbs p;                           

   Address         & nbsp;            &nb sp;              ;

   Name         &nbs p;                           

   Address         & nbsp;            &nb sp;              ;

   OR

   NOTARY:

   (If executed outside of RI by a Notary Public, attest in manner authorized by law of place where taken.)

   Sworn to (or affirmed) before me, this]]]]]]]] day of]]]]]]]]]]]]]] , 20]]]]]]]] .

   Notary Public

   My Commission Expires: ]]]]]]]]]]]]]]]]]]

   MAIL TO: BOARD OF CANVASSERS,

   Address

   City/TownRI Zip Code]]]]]]]]]]]]

   TO BE COMPLETED BY THE LOCAL BOARD OF CANVASSERS

   CITY/TOWN CODE

   CONG DIST

   SEN DIST

   REP DIST

   VOTE DIST

   WARD#

   DIST#

   ACCEPTED

   DATE

   Pursuant to § 17-20-8 of the election laws of the State of Rhode Island, "Any person knowingly and willfully making a false application or certification or knowingly and willfully aiding and abetting in the making of a false application or certification shall be guilty of a felony."

   Pursuant to § 17-26-1 of the election laws of the State of Rhode Island, "Felonies – Every person who shall be convicted of any offense under this title which has been classified by the general assembly as a felony, shall be imprisoned for a term of not more than ten (10) years, or be fined not less than one thousand dollars ($1,000) nor more than five thousand dollars ($5,000), or both, for each offense."