Ohio Rev. Code § 3511.05
Identification Envelope Statement of Voter
I, ________________________(Name of voter), declare under penalty of election falsification that the within ballot or ballots contained no voting marks of any kind when I received them, and I caused the ballot or ballots to be marked, enclosed in the identification envelope, and sealed in that envelope.
My voting residence in Ohio is
________________________________________________________________
(Street and Number, if any, or Rural Route and Number)
of ________________________________ (City, Village, or Township) Ohio, which is in Ward _______________ Precinct ________________ in that city, village, or township.
If I have a confidential voter registration record, I am providing my program participant identification number instead of my residence address: ________________________
The primary election ballots, if any, within this envelope are primary election ballots of the _____________ Party.
Ballots contained within this envelope are to be voted at the __________ (general, special, or primary) election to be held on the __________________________ day of ______________________, ____
My date of birth is _______________ (Month and Day), __________ (Year).
(Voter must provide one of the following:)
My Ohio driver's license or state identification card number is _______________ (Driver's license or state identification card number).
The last four digits of my Social Security Number are _______________ (Last four digits of Social Security Number).
______ In lieu of providing a driver's license or state identification card number or the last four digits of my Social Security Number, I am enclosing a copy of my photo identificationin the return envelope in which this identification envelope will be mailed.
I hereby declare, under penalty of election falsification, that the statements above are true, as I verily believe.
________________________
(Signature of Voter)
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.
Instructions to voter:
If the flap on this envelope is so firmly stuck to the back of the envelope when received by you as to require forcible opening in order to use it, open the envelope in the manner least injurious to it, and, after marking your ballots and enclosing same in the envelope for mailing them to the board of elections, reclose the envelope in the most practicable way, by sealing or otherwise, and sign the blank form printed below.
The flap on this envelope was firmly stuck to the back of the envelope when received, and required forced opening before sealing and mailing.
____________________
(Signature of voter)
R.C. § 3511.05