2009 Rhode Island Code
Title 17 - Elections
CHAPTER 17-20 - Mail Ballots
§ 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 ballot shall, in addition to those directions that may be printed, stamped, or written on it by authority of the secretary of state, be in substantially the following form:

   STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS 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 #]]]]]]]]]]]]]]]]]]

   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 THE FOLLOWING BASIS; (CHECK ONE ONLY)

   (     ) 1. I will be absent from the state on the date of the election during the entire period of time when the polls are to be open. Provide an out-of-state mailing address in BOX B above or the ballot will be mailed to the local board of canvassers.

   (     ) 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.

   Complete BOX B above with your entire address or the ballot will be mailed to the address in BOX A.

   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. Ballot will be mailed to address in BOX A.

   (      ) 4. I belong to a religion whose 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 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. Complete BOX B above or the ballot will be mailed to the local board of canvassers.

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

   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 No. 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 places where taken.)

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

   Notary Public

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