Title 17
Elections

STATE OF RHODE ISLAND EMERGENCY 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_________________________________________

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 not voting ballot at local board, ballot will be mailed to the address in BOX A above or to the Rhode Island address provided in BOX B above. If the ballot is to be delivered by the local board of canvassers to a person presenting written authorization to pick up the ballot, complete BOX A above and fill in the person’s name below.

I hereby authorize _______________________________________________________________________ to pick up my ballot at my local board of canvassers.

( ) 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 who will be outside the United States. If not voting ballot at local board, provide address in BOX B above.

( ) 4. I choose to vote by mail. 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.

I hereby authorize _______________________________________________________________________ to pick up my ballot at my local board of canvassers.

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. 2001, ch. 56, § 2; P.L. 2001, ch. 121, § 2; P.L. 2011, ch. 190, § 1; P.L. 2011, ch. 217, § 1; P.L. 2022, ch. 45, § 5, effective June 7, 2022; P.L. 2022, ch. 46, § 5, effective June 7, 2022.