§ 17-20-13.1. Form of emergency mail ballot application. The emergency mail ballot application to be subscribed by the voters before receiving a mail ballot shall, in addition to any directions that may be printed, stamped, or written on the application by authority of the secretary of state, be in substantially the following form:

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/TOWNSTATE........ 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 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.

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

Under the pains and penalty of perjury, I certify that on account of the following circumstances manifested twenty (20) days or less prior to the election for which I make this application. I will be unable to vote at the polls.

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.)