Rhode Island General Laws Title 17. Elections § 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:

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

( ) 1. 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. If the ballot is not being mailed to your voter registration address (BOX A above) please provide the Rhode Island address where you are temporarily residing in BOX B above.

( ) 2. I am confined in a hospital, convalescent home, nursing home, rest home, or similar institution within the State of Rhode Island. Provide the name and address of the facility where you are residing in BOX B above.

( ) 3. I am employed or in service intimately connected with military operations or because I am a spouse or dependent of such person, or I am a United States citizen and will be outside the United States. Complete BOX B above or the ballot will be mailed to the local board of canvassers.

( ) 4. I may not be able to vote at the polling place in my city or town on the day of the election. If the ballot is not being mailed to your voter registration address (BOX A above) please provide the address within the United States where you are temporarily residing in BOX B above. If you request that your ballot be sent to your local board of canvassers please indicate so in BOX B above.

BOX D OATH OF VOTER

I declare under the pains and penalty of perjury 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 blindness, disability, or inability to read or write, the applicant shall mark the box to indicate the voter cannot sign due to blindness, disability, or inability to read or write, and include the full name, residence address, signature, and optionally the telephone number and e-mail address of the person who provided assistance to the voter.

SIGNATURE IN FULL __________

Please note: A Power of Attorney signature is not valid in Rhode Island.