Medicaid Renewal Form

Page 1

Notice Date:

Respond By:

Case Number:

(M–F) 7AM – 8PM (Sat) 8AM – 5PM (Sun) Closed

Phone Hours:

(844)640-6446

Phone:

7-1-1

TDD - For the

Hearing Impaired:

Questions? Ask your worker.

It is time to renew your Medicaid coverage.

If you receive Medicaid, Medicare Premium Assistance, Long Term Care, or Waiver services, you must respond to this notice

to renew those services.

If you are unable to read English and need this form translated into your preferred language, contact your case worker.

Please call the number listed above for assistance.

Si no puede leer inglés y necesita este formulario traducido a su idioma preferido, póngase en contacto con el trabajador a

cargo de su caso. Por favor llame al número mencionado arriba para asistencia.

Haddii aanad awood u lahayn in aad akhrido oo aad u baahantahay in loo turjumo foomkan luqadda aad doorbidayso, la

xidhiidh shaqaalaha kiiskaaga. Fadlan wac lambarka kor ku qoran wixii caawimo ah.

You Can Renew Your - Online: If you have an online account, go to ssp.benefits.ohio.gov, logon and click

Medicaid in any on Renew My Benefits

one of these ways - By mail: Complete this form and mail it to your local County Department of Job and

Family Services (CDJFS)*.

- In person: Visit your local CDJFS*

- By phone: (844)640-6446

*Find the address to your local office at: jfs.ohio.gov/county/county_directory.pdf

How to complete 1. Answer all of the questions on the form. If you do not have all of the information

this renewal form asked for, still sign and submit this form.

2. Add any missing information. If any information has changed, cross out the old

information and write in the new information. If you need more space to provide

additional information about yourself or someone in your household or on your tax

return, print copies of the page or write the information on a separate sheet of paper

and attach it to this form.

3. Sign the form on page 9.

4. Respond to this form by . If you do not respond to this form

by the deadline, you will lose your Medicaid coverage.

What we need Information about each person living in your household or listed on your tax return

including employer and income information, for example: information from pay stubs,

W-2 forms, or wage and tax statements AND policy numbers for any current health

insurance.

What happens next? We will process your renewal. If you do not hear from us in 1-2 weeks, call

(844) 640-6446

If you, someone in your household or on your tax return is not already on Medicaid and would like to apply for health

insurance, a new application must be completed. You can apply online at healthcare.gov or benefits.ohio.gov or by calling

(844)640-6446 or in person at your local CDJFS.

Page 2

Your contact information

Home Address:

Mailing Address:

Phone:

Name (first, middle, last & suffix)

Home Address Apartment #

City (home) State Zip code

Mailing Address Apartment #

City (mailing) State Zip code

Best phone number to reach you:

Number:

Home Cell Work

Other phone number, if you have one:

Number:

Home Cell Work

Email Address:

I want to receive information by email

Voter Registration Application Attached - Help completing this form is available if you need it.

If you are not registered to vote where you live now, would you like to apply to register to vote today? If you do not check

either box, you will be considered to have decided not to register to vote at this time.

YES, I want to register. NO, I do not want to register to vote.

Do you want to apply for any of the following programs?

Healthy Start & Healthy Families (Medicaid) Nutritional Program for Women, Infants & Children (WIC)

Child & Family Health Services (CFHS) Bureau for Children with Medical Handicaps (BCMH)

Help Me Grow

We need information about who files tax returns.

You must renew even if you do not file a tax return.

Will anyone in the household file a federal tax return next year to report income earned this year?

If yes, answer all of the questions below.

If no, answer the question marked with a star * below

Person 1: Name (first, middle, last & suffix)

If this person is filing a joint return, write the name of the spouse:

If this person will claim dependents, write the names of the dependents:

Person 2: Name (first, middle, last & suffix)

This is for a second tax filer in the household

If this person is filling a joint return, write the name of the spouse:

If this person will claim dependents, write the names of the dependents:

* If anyone will be claimed as a dependent on someone else's tax return, write the name of the tax filer and the

dependents. Answer only if different than what you reported above or if you did not fill in any information above.

Name of tax filer: ___________________________________________________________________________________

Name of dependents: ________________________________________________________________________________

__________________________________________________________________________________________________

Page 3

We need information about these people

Person 1:

Please provide the person's date of birth: ___ / ___ / ______

Please provide the person's Social Security Number: ____ - ____ - ______

Check here if this

person is no longer

living in the household

and is not claimed on

your tax return

Please provide the following information:

Alien ID: _________________________________ Document Type: _________________________________________

Person 2:

Please provide the person's date of birth: ___ / ___ / ______

Please provide the person's Social Security Number: ____ - ____ - ______

Please provide the following information:

Alien ID: _______________________________ Document Type: _____________________________

Relationship to Person 1:

Check here if this

person is no longer

living in the household

and is not claimed on

your tax return

Person 3:

Please provide the person's date of birth: ___ / ___ / ______

Please provide the person's Social Security Number: ____ - ____ - ______

Please provide the following information:

Alien ID: _______________________________ Document Type: _____________________________

Relationship to Person 1:

Check here if this

person is no longer

living in the household

and is not claimed on

your tax return

Person 4:

Please provide the person's date of birth: ___ / ___ / ______

Please provide the person's Social Security Number: ____ - ____ - ______

Please provide the following information:

Alien ID: _______________________________ Document Type: _____________________________

Relationship to Person 1:

Check here if this

person is no longer

living in the household

and is not claimed on

your tax return

Person 5:

Please provide the person's date of birth: ___ / ___ / ______

Please provide the person's Social Security Number: ____ - ____ - ______

Please provide the following information:

Alien ID: _______________________________ Document Type: _____________________________

Relationship to Person 1:

Check here if this

person is no longer

living in the household

and is not claimed on

your tax return

Page 4

We need more information about people

not listed in Section 3 (page 3)

Tell us about anybody else in your household or on your tax return that is not listed in Section 3.

Name of other person: (first, middle, last & suffix):

Please provide the person's Social Security Number.

____ - ____ - ______

This person may choose not to give the Social Security Number, but it

helps us to have it.

Check here if this person has Medicaid.

Check here if this person is no longer living in the household.

Date of birth (month/ day/ year):

Male Female

This person is:

How is this person related to you?

Name of other person: (first, middle, last & suffix):

Please provide the person's Social Security Number.

____ - ____ - ______

This person may choose not to give the Social Security Number, but it

helps us to have it.

Check here if this person has Medicaid.

Check here if this person is no longer living in the household.

Date of birth (month/ day/ year):

Male Female

This person is:

How is this person related to you?

Name of other person: (first, middle, last & suffix):

Please provide the person's Social Security Number.

____ - ____ - ______

This person may choose not to give the Social Security Number, but it

helps us to have it.

Check here if this person has Medicaid.

Check here if this person is no longer living in the household.

Date of birth (month/ day/ year):

Male Female

This person is:

How is this person related to you?

Name of other person: (first, middle, last & suffix):

Please provide the person's Social Security Number.

____ - ____ - ______

This person may choose not to give the Social Security Number, but it

helps us to have it.

Check here if this person has Medicaid.

Check here if this person is no longer living in the household.

Date of birth (month/ day/ year):

Male Female

This person is:

How is this person related to you?

Name of other person: (first, middle, last & suffix):

Please provide the person's Social Security Number.

____ - ____ - ______

This person may choose not to give the Social Security Number, but it

helps us to have it.

Check here if this person has Medicaid.

Check here if this person is no longer living in the household.

Date of birth (month/ day/ year):

Male Female

This person is:

How is this person related to you?

Tell us about other health insurance coverage people have

Include anyone in Section 3 and 4.

Name of insurance company: Policy number:

Type of insurance:

Other insurance ________________________ Veteran's health coverage Medicare Tricare

List everyone who is on this policy:

Check here if this is a limited benefit policy

Name of insurance company: Policy number:

Type of insurance:

Other insurance ________________________ Veteran's health coverage Medicare Tricare

List everyone who is on this policy:

Check here if this is a limited benefit policy

Check here if anyone on this form is offered health insurance through a job, even if they are not enrolled.

Tell us who. Name: ____________________________________________________________________

Page 5

Tell us more about the people listed on this form

Is anyone pregnant?

Name (first, middle, last & suffix):

How many babies are expected? Due Date:

Name (first, middle, last & suffix):

How many babies are expected? Due Date:

Is anyone between the ages of 18 and 26 and was in foster care and in receipt of Ohio Medicaid on his or her

18th birthday?

Name (first, middle, last & suffix):

Is anyone blind or disabled?

Name (first, middle, last & suffix):

Does anyone have a medical, mental health, or substance use condition that limits his or her ability to work,

go to school, or take care of daily activities (like bathing or dressing)?

Name (first, middle, last & suffix):

Does anyone live in a long term care facility, group home, or nursing home, or regularly gets medical

care, personal care, or health services at home or in another community setting (like adult day care)?

Name (first, middle, last & suffix):

Is anyone between the ages of 18 and 22 and also a full-time student?

Name (first, middle, last & suffix):

Page 6

Tell us about work

Fill in the information below for everyone in your household or on your tax return who has

income from a job (not self-employed). If someone has more than one job, tell us about all jobs.

You can tell us about self-employment on the next page.

Job 1: Name of the person who is working (first, middle, last & suffix):

Employer name: Employer phone number:

Employer address:

How often are wages or tips paid?

Hourly Weekly Every two weeks Twice a month Monthly Yearly

How much does this person get paid (before taxes)? $ Average hours worked each week:

Job 2: Name of the person who is working (first, middle, last & suffix):

Employer name: Employer phone number:

Employer address:

How often are wages or tips paid?

Hourly Weekly Every two weeks Twice a month Monthly Yearly

How much does this person get paid (before taxes)? $ Average hours worked each week:

Job 3: Name of the person who is working (first, middle, last & suffix):

Employer name: Employer phone number:

Employer address:

How often are wages or tips paid?

Hourly Weekly Every two weeks Twice a month Monthly Yearly

How much does this person get paid (before taxes)? $ Average hours worked each week:

Job 4: Name of the person who is working (first, middle, last & suffix):

Employer name: Employer phone number:

Employer address:

How often are wages or tips paid?

Hourly Weekly Every two weeks Twice a month Monthly Yearly

How much does this person get paid (before taxes)? $ Average hours worked each week:

Job 5: Name of the person who is working (first, middle, last & suffix):

Employer name: Employer phone number:

Employer address:

How often are wages or tips paid?

Hourly Weekly Every two weeks Twice a month Monthly Yearly

How much does this person get paid (before taxes)? $ Average hours worked each week:

Section 7 continued on next page > > >

Page 7

Section 8 continued on next page > > >

Tell us about work (continued)

List anyone in your household or on your tax return who has changed jobs or has worked fewer hours in the

past four months.

1. Name (first, middle, last & suffix):

This person stopped working This person is now working fewer hours This person changed jobs

2. Name (first, middle, last & suffix):

This person stopped working This person is now working fewer hours This person changed jobs

List anyone in your household or on your tax return who is self-employed

Subtract the expenses below from your gross income to get an amount for your net self-employment income.

- Car and truck expenses (for travel during the workday, not commuting)

- Depreciation

- Employee wages and fringe benefits

- Property, liability, or business interruption insurance

- Interest (including mortgage interest paid to banks, etc.)

- Legal and professional services

- Rent or lease of business property and utilities

- Commissions, taxes, licenses and fees

- Advertising

- Contract labor

- Repairs and maintenance

- Certain business travel and meals

- Deductible self-employment taxes

- Cost of self-employed health insurance

- Contributions to self-employed SEP, SIMPLE, or

qualified retirement plan

1. Name (first, middle, last & suffix):

Type of work:

How much net income will this person get from self-employment this month? Amount:

2. Name (first, middle, last & suffix):

Type of work:

How much net income will this person get from self-employment this month? Amount:

Tell us about other income

List the names of anyone whose income changes from month to month.

1. Name (first, middle, last & suffix):

What do you expect his or her income to be this year? Amount:

I do not know what their income will be.

2. Name (first, middle, last & suffix):

What do you expect his or her income to be this year? Amount:

I do not know what their income will be.

3. Name (first, middle, last & suffix):

What do you expect his or her income to be this year? Amount:

I do not know what their income will be.

Unemployment Compensation How much? How often?

Name (first, middle, last & suffix):

Weekly Every two weeks

Monthly

Other

Yearly

Twice a month

Social Security How much? How often?

Page 8

Tell us about other income (continued)

Name (first, middle, last & suffix):

Weekly Every two weeks

Monthly

Other Yearly

Twice a month

Pensions How much? How often?

Name (first, middle, last & suffix):

Weekly Every two weeks

Monthly

Other

Twice a month

Yearly

Retirement accounts How much? How often?

Name (first, middle, last & suffix):

Weekly Every two weeks

Monthly

Other

Yearly

Twice a month

Alimony received How much? How often?

Name (first, middle, last & suffix):

Weekly Every two weeks

Yearly Monthly

Twice a month

Other

Farming or fishing (profit after business expenses)

How much? How often?

Name (first, middle, last & suffix):

Weekly Every two weeks

Monthly

Yearly

Twice a month

Other

Rental income or royalties (profit after business expenses) How much? How often?

Name (first, middle, last & suffix):

Weekly Every two weeks

Monthly

Twice a month

Yearly Other

Other income Type: How much? How often?

Name (first, middle, last & suffix):

Weekly Every two weeks

Monthly

Other

Twice a month

Yearly

Other income Type: How much? How often?

Name (first, middle, last & suffix):

Weekly

Monthly

Every two weeks

Other

Twice a month

Yearly

If anyone in your household has tax deductions, tell us what kind.

Alimony paid to someone else How much? How often?

Name (first, middle, last & suffix):

Weekly Every two weeks

Monthly Other

Twice a month

Yearly

Student loan interest paid How much? How often?

Name (first, middle, last & suffix):

Weekly Every two weeks

Monthly Other Yearly

Twice a month

Other Deductions Type: How much? How often?

Name (first, middle, last & suffix):

Weekly Every two weeks

Monthly Other

Twice a month

Yearly

Page 9

Read and sign this application

Renewal of coverage in future years

Read the following statement and check one box: To make it easier to electronically verify my income at renewal time, I give the

Ohio Department of Medicaid permission to use computer data information from my federal tax returns, provided by the IRS, for the

number of years I checked below. I understand that the Ohio Department of Medicaid will send me the information it has verified and

I will have a chance to correct and update this information. I can also change my mind, at any time, and not allow the Ohio

Department of Medicaid to check this information.

Yes, I give permission to use computer data information from my federal tax returns, provided by the IRS, to electronically verify my

income for (check one box):

5 years (the longest time) 4 years 3 years 2 years 1 year

No, I do not give permission to use my tax returns.

Your rights and responsibilities

- I am signing this renewal form under penalty of perjury which

means I have provided true answers to all the questions on this

form to the best of my knowledge. I know that I may be subject to

penalties under federal law if I provide false and/or untrue

information.

- I know that I must tell the Ohio Department of Medicaid if anything

changes (and is different from) what I wrote on this form. I can

call (844) 640-6446 to report any changes within 10 days. I

understand that a change in my information could affect the

eligibility for member(s) of my household.

- I know that under federal law, discrimination is not permitted on

the basis of race, color, national origin, sex, age, sexual

orientation, gender identity, or disability. I can file a complaint of

discrimination by visiting www.hhs.gov/ocr/office/file.

- I understand that the Ohio Department of Medicaid will get

information about my financial resources from banks, credit

unions, or other financial institutions in order to determine my

eligibility for medical assistance. Authorization to get this

information remains in effect until:

• My application for medical assistance is denied; or

• My eligibility for medical assistance ends; or

• I inform the Ohio Department of Medicaid in writing that I

wish to end my authorization.

- If I refuse to authorize the Ohio Department of Medicaid to get

information about me from financial institutions, or I decide to

end my authorization, I understand that my medical assistance

may be denied or discontinued.

If anyone on this application is eligible for Medicaid

- I am giving the Ohio Department of Medicaid our rights to pursue

and get any money from other health insurance, legal

settlements, or other third parties. I am also giving the Ohio

Department of Medicaid our rights to pursue and get medical

support from an ex-spouse or parent.

- I authorize any person who furnishes health care or medical

supplies or services to give the Ohio Department of Medicaid,

the Ohio Department of Job & Family Services, or the Ohio

Department of Health any information related to the extent,

duration, and scope of services provided under the Medicaid

program, WIC, and other medical assistance programs. I also

authorize the previously mentioned departments to exchange

any information I have provided on this form, to enable the

departments to determine my eligibility.

- I understand that if I do not qualify for Medicaid, the Ohio

Department of Medicaid may send my information to another

program so they can see if I qualify.

- The Ohio Department of Medicaid will check my answers using

information from computer data sources, including the Internal

Revenue Service (IRS), the Social Security Administration, the

Department of Homeland Security and others. If the information

does not match, the Ohio Department of Medicaid may ask me to

send more information.

- I understand that, after my death, Ohio Department of Medicaid

can file a claim against my estate to recover money that the state

paid for coverage provided to me. This process must happen if I

am in a medical institution and not expected to return home, or if

I am 55 years of age or older and the state pays for my nursing

facility services, home and community based services, or related

hospital and prescription drug services. The amount recovered

by the Ohio Department of Medicaid will not be more than the

amount Medicaid paid for my care.

- I understand that the Ohio Department of Medicaid is authorized

to collect information on this form, and other supporting

information including Social Security numbers, under the Patient

Protection and Affordable Care Act (Public Law No. 111-148), as

amended by the Health Care Education Reconciliation Act of

2010 (Public Law 111-152) and the Social Security Act.

- Does any child on this renewal form have a parent living outside

of the home?

- If yes, I know I will be asked to cooperate with the agency

that collects medical support from an absent parent. If I think

that cooperating to collect medical support will harm me or

my children, I can tell Medicaid and I may not have to

cooperate.

- I understand that when I send in this form, it means I have

permission from everyone whose information is on the form to

submit their information to Ohio Department of Medicaid and

receive any communications about their eligibility and enrollment.

Yes

My right to appeal

If I think that the Ohio Department of Medicaid or the Health

Insurance Marketplace has made a mistake I can appeal its

decision. To appeal means to tell someone at the Ohio Department

of Medicaid or the Health Insurance Marketplace that I think the

action is wrong and ask for a fair review of the action. I know that I

can find out how to appeal by contacting the Ohio Department of

Medicaid at (844) 640-6446. I know that I can be represented in

the process by someone other than myself. My eligibility and other

important information will be explained to me.

Sign and date below. If you want an authorized representative or want to change the authorized representative you have

now, fill out Attachment A on page 10. The last page is a Voter Registration From and is not part of your Medicaid renewal.

If you wish to register to vote, fill that form out and return it separately to your county board of elections.

Check here if you are an authorized representative. Sign below and fill out Attachment A on page 10.

Signature of household contact or authorized representative: Date:

Page 10

Attachment A

Assistance with completing this renewal form

You can give a trusted person permission to talk about this renewal form with us, see your information, and act

for you on matters related to this form, including getting information about your renewal and signing your form

on your behalf. This person is called an "authorized representative." If you ever need to change your

authorized representative, contact your local County Department of Job and Family Services. If you're a legally

appointed representative for someone on this application, submit proof with this form.

We show that you chose this person as your authorized representative: Do you still want this person to be your authorized representative

Yes No

If yes, has any of his or her information changes?

Yes No

If you have an authorized representative now, please answer these questions.

If your authorized representative's information has changed, or if you would like a different authorized representative,

please write the new information below:

Name of authorized representative:

Address: Apartment # City State Zip code

Phone number:

Number:

Home Cell Work Other

By signing, you allow this person to sign your renewal form, to get information about this renewal form, and to act for you with this agency.

Your signature: Date:

If you do not have an authorized representative and want one, please answer these questions.

Check here if you are an authorized representative. Answer the questions below.

Name of authorized representative:

Address: Apartment # City State Zip code

Phone number:

Number:

Other Work Cell Home

By signing, you allow this person to sign your renewal form, to get information about this renewal form, and to act for you with this agency.

Your signature: Date:

Voter Registration and Information Update Form

Please read instructions carefully. Please type or print clearly with blue or black ink.

For further information, you may consult the Secretary of State’s website at: www.OhioSecretaryofState.gov or call (877) 767-6446.

Eligibility

You are qualified to register to vote in Ohio if you meet all the

following requirements:

1. You are a citizen of the United States.

2. You will be at least 18 years old on or before the day of the

general election.

3. You will be a resident of Ohio for at least 30 days

immediately before the election in which you want to vote.

4. You are not incarcerated (in jail or in prison) for a felony

conviction.

5. You have not been declared incompetent for voting

purposes by a probate court.

6. You have not been permanently disenfranchised for

violations of election laws.

Use this form to register to vote or to update your current Ohio

registration if you have changed your address or name.

NOTICE: This form must be received or postmarked by the 30th day

before an election at which you intend to vote. You will be notified by

your county board of elections of the location where you vote. If you

do not receive a notice following timely submission of this form,

please contact your county board of elections.

Numbers 1 and 2 below are required by law. You must answer

both of the questions for your registration to be processed.

Registering in Person

If you have a current valid Ohio driver’s license, you must provide that

number on line 10. If you do not have an Ohio driver’s license, you

must provide the last four digits of your Social Security number on

line 10. If you have neither, please write “None.”

Registering by Mail

If you register by mail and do not provide either an Ohio driver’s

license number or the last four digits of your Social Security number,

you must enclose with your application a copy of one of the following

forms of identification:

Current and valid photo identification, a military identification, or a

current (within the last 12 months) utility bill, bank statement,

government check, paycheck, or government document (other than

a notice of voter registration mailed by a board of elections) that

shows the voter’s name and current address.

Residency Requirements

Your voting residence is the location that you consider to be a

permanent, not a temporary, residence. Your voting residence is the

place in which your habitation is fixed and to which, whenever you

are absent, you intend to return. If you do not have a fixed place of

habitation, but you are a consistent or regular inhabitant of a shelter

or other location to which you intend to return, you may use that

shelter or other location as your residence for purposes of registering

to vote. If you have questions about your specific residency

circumstances, you may contact your local board of elections for

further information.

Your Signature

In the area below the arrow in Box 14, please write your cursive,

hand-written signature or make your legal mark, taking care that it

does not touch the surrounding lines so when it is digitally imaged by

your county board of elections it can effectively be used to identify

your signature.

Please see information on back of this form to learn how

to obtain an absentee ballot.

WHOEVER COMMITS ELECTION FALSIFICATION IS

GUILTY OF A FELONY OF THE FIFTH DEGREE

Registering as an Ohio voter

Updating my address

Updating my name

I am:

1. Are you a U.S. citizen?

Yes

2. Will you be at least 18 years of age on or before the next general election?

Yes

If you answered NO to either of the questions, do not complete this form.

3. Last Name First Name Middle Name or Initial Jr., II, etc.

4. House Number and Street (Enter new address if changed) Apt. or Lot # 5. City or Post Office 6. ZIP Code

7. Additional Mailing Address (if necessary)

8. County

(where you live)

9. Birthdate (MM/DD/YYYY) (required)

10. Ohio Driver’s License number OR Last Four

Digits of Social Security number (one form of ID

required to be listed or provided)

11. Phone Number (voluntary)

12. PREVIOUS ADDRESS IF UPDATING CURRENT REGISTRATION - Previous House Number and Street

Previous City or Post Office

County

State

13. CHANGE OF NAME ONLY Former Legal Name

Former Signature

14.

I declare under penalty of

election falsification I am a

citizen of the United States, will

have lived in this state for 30

days immediately preceding the

next election, and will be at least

18 years of age at the time of

the general election.

Your Signature

Date

(MM/DD/YYYY)

FOR BOARD

USE ONLY

SEC4010 (rev. 4/15)

City, Village, Twp.

Ward

Precinct

School Dist.

Cong. Dist.

Senate Dist.

House Dist.

TO ENSURE YOUR INFORMATION IS RECEIVED,

PLEASE DO THE FOLLOWING:

1. Print this form.

2. Make sure all required fields are complete.

3. Sign and date your form.

4. Fold and insert your form into an envelope.

5. Mail your form to your county board of elections.

For your county board's address please visit www.OhioSecretaryofState.gov/boards.htm

If you have additional questions, please call the office of the Ohio

Secretary of State at (877) SOS-OHIO (877-767-6446).

HOW TO OBTAIN AN OHIO ABSENTEE BALLOT

You are entitled to vote by absentee ballot in Ohio without providing a reason. Absentee

ballot applications may be obtained from your county board of elections or from the

Secretary of State at: www.OhioSecretaryofState.gov or by calling (877) 767-6446.

OHIO VOTER IDENTIFICATION REQUIREMENTS

Voters must bring identification to the polls in order to verify identity. Identification may

include current and valid photo identification, a military identification, or a copy of a

current (within the last 12 months) utility bill, bank statement, government check,

paycheck, or other government document (other than a notice of voter registration

mailed by a board of elections) that shows the voter’s name and current address. Voters

who do not provide one of these documents will still be able to vote by providing the last

four digits of the voter’s Social Security number and by casting a provisional ballot

pursuant to R.C. 3505.181. For more information on voter identification requirements,

please consult the Secretary of State’s website at: www.OhioSecretaryofState.gov or

call (877) 767-6446.

WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A

FELONY OF THE FIFTH DEGREE.

To help you understand this notice, language assistance, interpretation services, and auxiliary aids and services are available upon request at no cost to you.

Services available include, but are not limited to: oral translation, written translation, and auxiliary aids. You can request these services and/or auxiliary aids by

calling County Shared Services at the toll-free phone number 1-844-640-6446; individuals with a hearing impairment may call TDD 7-1-1.

Spanish:

Para ayudarle a entender este aviso, se ofrecen asistencia con el idioma, servicios de interpretación y ayudas y servicios auxiliares a solicitud sin costo alguno

para usted. Los servicios disponibles incluyen, entre otros, traducción oral, traducción por escrito y ayudas auxiliares. Para solicitar estos servicios o ayudas

auxiliares, llame sin costo a Servicios Compartidos del Condado al teléfono 1-844-640-6446; las personas con discapacidad auditiva pueden llamar a TDD 7-1-1.

Arabic

.ﺔﻔﻠﻜﺗ يأ نوﺪﺑو ﺎ

ﻧﺎﺠﻣ ﺐﻠﻄﻟا ﺪﻨﻋ ةﺪﻋﺎﺴﻤﻟا تﺎﻣﺪﺨﻟاو تاودﻷاو ﺔﯾرﻮﻔﻟا ﺔﻤﺟﺮﺘﻟا تﺎﻣﺪﺧو ﺔﯾﻮﻐﻠﻟا ةﺪﻋﺎﺴﻤﻟا ﺮﻓﻮﺘﺗ ،رﺎﻄﺧﻹا اﺬھ ﻢﮭﻓ ﻰﻠﻋ ﻚﺗﺪﻋﺎﺴﻤﻟ

.ةﺪﻋﺎﺴﻤﻟا تاودﻷاو ﺔﯾﺮﯾﺮﺤﺘﻟا ﺔﻤﺟﺮﺘﻟاو ﺔﯿﮭﻔﺸﻟا ﺔﻤﺟﺮﺘﻟا :ﺮﺼﺤﻟا ﻻ لﺎﺜﻤﻟا ﻞﯿﺒﺳ ﻰﻠﻋ ،ﺔﺣﺎﺘﻤﻟا تﺎﻣﺪﺨﻟا ﻞﻤﺸﺗ

ﻲﺼﻨﻟا ﻒﺗﺎﮭﻟا ﻢﻗﺮﺑ لﺎﺼﺗﻻا ﻊﻤﺴﻟا ﻒﻌﺿ ﻦﻣ نﻮﻧﺎﻌﯾ ﻦﯾﺬﻟا داﺮﻓﻸﻟ ﻦﻜﻤﯾ ؛ 1-844-640-6446 ﻲﻧﺎﺠﻤﻟا ﻒﺗﺎﮭﻟا ﻢﻗر ﻰﻠﻋ ﺔﻛﺮﺘﺸﻤﻟا ﺔﻌﻃﺎﻘﻤﻟا تﺎﻣﺪﺨﺑ لﺎﺼﺗﻻا ﻖﯾﺮﻃ ﻦﻋ ةﺪﻋﺎﺴﻤﻟا تاودﻷا وأ/و تﺎﻣﺪﺨﻟا هﺬھ ﺐﻠﻃ ﻚﻨﻜﻤﯾ

. 7-1-1

Somali:

Si lagaaga caawiyo inaad fahanto ogeysiiskan, caawin luqadeed, adeegyada turjumaanka, iyo qalabka iyo adeegyada naafada ayaa la heli karaa marka la

codsado iyadoo aan kharash kaa bixin. Adeegyada la heli karo waxaa ka mid ah, laakiine aan ku xaddidnayn: Tarjumaadda afka ah, turjumaad qoraalka ah, iyo

qalabka naafada. Waxaad ku codsan kartaa adeegyadaa iyo/ama qalabka naafada adigoo ka wacaya Adeegyada la wadaago ee degmada (County Shared

Services) taleefanka lacah la’aanta ah ee lambarka 1-844-640-6446; Dadka maqalka ku dhiban waxay wici karaan TDD 7-1-1.

Russian:

Чтобы помочь вам понять это уведомление, по вашему запросу бесплатно предоставляется языковая помощь, услуги устного перевода, а также

дополнительные средства и услуги. В число доступных услуг входят, в частности, устный перевод, письменный перевод и вспомогательные средства.

Вы можете обратиться за этими услугами и/или вспомогательными средствами, позвонив в County Shared Services по бесплатному телефону

1-844-640-6446; лица с нарушением слуха могут позвонить по номеру TDD 7-1-1.

French:

Pour vous aider à comprendre cette communication, une assistance linguistique, des services de traduction et des aides/services auxiliaires sont disponibles

gratuitement sur demande. Les services disponibles comprennent, entre autres : traduction orale, traduction écrite et aides-auxiliaires. Vous pouvez consulter

ces services et/ou des aides-auxiliaires en appelant les Services Partagés des Comtés (County Shared Services) au numéro gratuit suivant : 1-844-640-6446 ;

les personnes ayant une déficience auditive peuvent appeler TDD 7-1-1.

Vietnamese:

Để giúp quý vị hiểu được thông báo này, dịch vụ hỗ trợ ngôn ngữ, dịch vụ thông dịch và các dịch vụ và trợ giúp bổ sung được cung cấp miễn phí cho quý vị khi

có yêu cầu. Các dịch vụ có sẵn bao gồm nhưng không giới hạn ở: phiên dịch miệng, biên dịch và trợ giúp bổ sung. Quý vị có thể yêu cầu các dịch vụ này và/

hoặc trợ giúp bổ sung bằng cách gọi cho Dịch vụ Chia sẻ của Quận theo số điện thoại miễn cước 1-844-640-6446; người khiếm thính có thể gọi đến TDD 7-1-1.

Swahili:

Ili kukusaidia kuelewa notisi hii, usaidizi wa lugha, huduma za ukalimani, na vifaa vya kusikia na huduma za kusikia zinapatikana ukiomba bila gharama yoyote

kwako. Huduma zinazopatikana zinajumuisha, lakini sio tu: tafsiri kwa usemi, tafsiri kwa maandishi, na vifaa vya kusikia. Unaweza kuomba huduma hizi na/au

vifaa vya kusikia kwa kupiga simu kwa County Shared Services (Huduma Zinazoshirikiwa za Kaunti) kwa nambari ya simu ya bila malipo 1-844-640-6446; watu

walio na ulemavu wa kusikia wanaweza kupiga simu kwa TDD 7-1-1.

Ukrainian:

Для того, щоб Ви могли зрозуміти це повідомлення, за Вашим запитом безкоштовно надається мовна підтримка, послуги усного перекладу, а також

допоміжні засоби та послуги. Послуги, що надаються, охоплюють, серед іншого: усні та письмові переклади, а також допоміжні засоби. Ви можете

отримати ці послуги та/або допоміжні засоби, зателефонувавши до Центру надання муніципальних послуг округу за безкоштовним телефоном

1-844-640-6446;

особи з вадами слуху можуть зателефонувати за номером 7-1-1 за допомогою телекомунікаційного приладу для глухих.

Kinyarwanda (Burundi):

Kugira ngo tugufasha gusobanukirwa iri tangazo, ubwunganizi mu by’indimi, serivisi z’ubusemuzi n’ubufasha na serivisi by’ibanze btangwa iyo ubisabye kandi nta

kiguzi. Serivisi zitangwa zikubiyemo, ariko ntizigarukira kuri: ubusemuzi mu magambo, ubusemuzi mu nyandiko, n’ubufasha bw’ibanze. Ushobora gusaba izi

serivisi no/cyangwa ubufasha bw’ibanze uhamagara County Shared Services kuri terefone itishyurwa nomero 1-844-640-6446; abantu bafite ubumuga bwo

kutumva bashobora guhamagara TDD 7-1-1.

Afghani

ﯽﻟو ،دﻮﺷ ﯽﻣ دراﻮﻣ ﻦﯾا ﻞﻣﺎﺷ دﻮﺟﻮﻣ تﺎﻣﺪﺧ .ﺖﺳا دﻮﺟﻮﻣ ﺎﻤﺷ یاﺮﺑ نﺎﮕﯾار رﻮﻄﺑ ﺖﺳاﻮﺧرد ﻦﯿﺣ یﻮﯾﺎﻤﺣ تﺎﻣﺪﺧ و ﺎھ ﮏﻤﮐ و ﯽھﺎﻔﺷ ﮫﻤﺟﺮﺗ تﺎﻣﺪﺧ ،نﺎﺑز تﺪﻋﺎﺴﻣ ،ﺪﯿﻨﮐ کرد ار ﮫﯿﻋﻼﻃا ﻦﯾا ﺎﺗ ﻢﯿﻨﮐ نﺎﺗ ﮏﻤﮐ ﮫﮑﻨﯾا یاﺮﺑ

نﺎﮕﯾار هرﺎﻤﺷ ﺎﺑ County Shared Services ﮫﺑ ندز ﮓﻧز ﺎﺑ ار یﻮﯾﺎﻤﺣ یﺎھ ﮏﻤﮐ ﺎﯾ/و تﺎﻣﺪﺧ ﻦﯾا ﺪﯿﻧاﻮﺘﯿﻣ ﺎﻤﺷ .یﻮﯾﺎﻤﺣ یﺎھ ﮏﻤﮐ و ﯽﺒﺘﮐ ﮫﻤﺟﺮﺗ ،ﯽھﺎﻔﺷ ﮫﻤﺟﺮﺗ :ﺪﺷﺎﺑ ﯽﻤﻧ دراﻮﻣ ﻦﯾا ﮫﺑ دوﺪﺤﻣ ﺎﮭﻨﺗ

.ﺪﻨﻧﺰﺑ ﮓﻧز TDD 7-1-1 هرﺎﻤﺷ ﮫﺑ ﺪﻨﻧاﻮﺘﯿﻣ ﺪﻧراد ﻞﮑﺸﻣ ﯽﯾاﻮﻨﺷ ﺶﺨﺑ رد ﮫﮐ یداﺮﻓا ؛ﺪﯿﻨﮐ ﺖﺳاﻮﺧرد 6446-640-844-1