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
APPLICATION OF VOTER FOR BALLOT FOR ELECTION
ON _______________________________________
(COMPLETE HIGHLIGHTED SECTIONS)
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/TOWN _____________________________________ STATE RI ZIP CODE _________
DATE OF BIRTH _____________________________________ PHONE # _________
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 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 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 _________
Please note: A Power of Attorney signature is not valid in Rhode Island.
History of Section.
P.L. 1978, ch. 258, § 2; P.L. 1980, ch. 407, § 1; P.L. 1983, ch. 172, § 13; P.L. 1985, ch. 161, § 1; P.L. 1987, ch. 282, § 1; P.L. 1989, ch. 435, § 1; P.L. 1990, ch. 227, § 1; P.L. 1990, ch. 498, § 1; P.L. 1991, ch. 314, § 1; P.L. 1992, ch. 205, § 1; P.L. 1992, ch. 260, § 1; P.L. 1999, ch. 83, § 41; P.L. 1999, ch. 130, § 41; P.L. 2001, ch. 56, § 1; P.L. 2001, ch. 121, § 1; P.L. 2005, ch. 119, § 3; P.L. 2005, ch. 167, § 3; P.L. 2011, ch. 190, § 1; P.L. 2011, ch. 217, § 1.