Form No.

10-A Prescribed by the Secretary of State (01-19)

Voter Registration Cancellation print clearly

R.C. 3503.21

Please help us keep Ohio's Voter Registration Rolls up-to-date. To cancel your Ohio voter registration:
1. Complete, print and sign the cancellation form below.

2. Insert it into an envelope.

3. Add your former Ohio county board of elections address on the envelope.

4. Affix a stamp in the appropriate location.

5. Mail your cancellation.

If you do not know the address of your former Ohio county board of elections, visit our website:
www.MyOhioVote.com/board.htm.

To find information on how to register to vote in another state, visit the U.S. Election Assistance
Commission’s website: www.eac.gov/voter_resources/register_to_vote.aspx.

OHIO VOTER REGISTRATION CANCELLATION REQUEST R.C. 3503.21 (Form No. 10-A)
I hereby request the cancellation of my voter registration in the State of Ohio.

My registration on file with the county board of elections is:

Full Name First Middle

Required
1
Last Suffix

Date of Birth
Required 2 Date of Birth (Do not write today's date here)

Address at Which Street Address (No P.O. Boxes) ZIP

you are Registered
to Vote in Ohio 3
Required City/Village/Township

Signature
Required
Signature X
4
Today's Date MM/DD/YYYY

The filing of this request does not prohibit you from reregistering to vote at any time in the future.