§ 17-20-13.1 - Form of Emergency Mail Ballot Application.
SECTION 17-20-13.1
§ 17-20-13.1 Form of Emergency Mail BallotApplication. – The emergency mail ballot application to be subscribed by the voters beforereceiving a mail ballot shall, in addition to any directions that may beprinted, stamped, or written on the application by authority of the secretaryof state, be in substantially the following form:
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONSEMERGENCY APPLICATION OF VOTER FOR BALLOT FOR ELECTION ON]]]]]]]]
=hd15 (COMPLETE HIGHLIGHTED SECTIONS)
=hd16 NOTE – THIS APPLICATION MUST BE RECEIVED BYTHE 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 ZIPCODE]]]]]]]]]]]]
DATE OF BIRTHPHONE#]]]]]]]]]]]]]]
BOX B (PRINT OR TYPE)
NAME OF INSTITUTION (IF APPLICABLE)
ADDRESS
ADDRESS
CITY/TOWNSTATE]]]]]]]] ZIP CODE]]]]]]]]]]]]
I CERTIFY THAT I AM ELIGIBLE FOR A MAIL BALLOT ON THEFOLLOWING BASIS: (CHECK ONE ONLY)
( ) 1. I will beabsent from the state on the day of the election during the entire period oftime 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 beabsent from the city or town of my voting residence during the entire period oftime when the polls are to be open because of my status as a student, or spouseof a student, at an institution of higher learning within the state of RhodeIsland. If not voting ballot at local board, provide address in BOX B above.Indicate name of institution.
( ) 3. I amincapacitated to such an extent that it would be an undue hardship to vote atthe polls because of illness, mental or physical disability, blindness or aserious impairment of mobility. Medical form R-50 must be completed. If notvoting ballot at local board, ballot will be delivered to address in BOX Aabove.
( ) 4. I belong to areligion whose tenets forbid secular activity, including voting, on the day ofelection. If not voting ballot at local board, ballot will be delivered toaddress in BOX A above.
( ) 5. I am confinedin a hospital, convalescent home, nursing home, rest home, or similarinstitution. Complete BOX B above.
( ) 6. I am detainedwhile awaiting trial or imprisoned for a cause other than final conviction of afelony. Complete BOX B above.
( ) 7. I am employedor in service intimately connected with military operations or because I am aspouse or dependent of such person. If not voting ballot at local board,provide address in BOX B above.
( ) 8. I am employedby 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 workerassigned to work Election Day outside of their voting district.
Under the pains and penalty of perjury, I certify that onaccount of the following circumstances manifested twenty (20) days or lessprior to the election for which I make this application. I will be unable tovote at the polls.
Circumstances necessitating mail ballot: (Please describebelow if checking category 1, 2, 4, 5, 6, 7 or 8)
I declare that all of the information I have provided on thisform is true and correct to the best of my knowledge. I further state that I amnot a qualified voter of any other city or town or state and have not claimedand 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 orotherwise, applicant shall make his or her mark "X".
SIGNATURE IN FULL
This application must either be sworn to before a notarypublic OR before two (2) witnesses who must sign their names and affix theiraddresses. No witness or notary is necessary if checking category #7.
WITNESSES:
Name
Address
Name
Address
OR
NOTARY:
(If executed outside of RI by a Notary Public, attest inmanner authorized by law of place where taken.)
Sworn to (or affirmed) before me, this]]]]]]]] dayof]]]]]]]]]]]]]] , 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 Stateof Rhode Island, "Any person knowingly and willfully making a false applicationor certification or knowingly and willfully aiding and abetting in the makingof a false application or certification shall be guilty of a felony."
Pursuant to § 17-26-1 of the election laws of the Stateof Rhode Island, "Felonies – Every person who shall be convicted of anyoffense under this title which has been classified by the general assembly as afelony, shall be imprisoned for a term of not more than ten (10) years, or befined not less than one thousand dollars ($1,000) nor more than five thousanddollars ($5,000), or both, for each offense."