Ohio Secretary of State

Elections/Certification Division

Date: _______________________

Name:___________________________________________________

Address: ________________________________________________________________

              _________________________________________________________________

Daytime Telephone Number: _________________________________________

Country documents are prepared for: ____________________________________

Return address of document(s) if DIFFERENT from the above address:

________________________________________________________________________

Confirm this checklist prior to submitting your documents:

____ Check or Money Order payable to Ohio Secretary of State $5.00 per authentication

____ Documents that require county certification have been county certified

____ Name of the country of destination has been provided

____ Enclosed prepaid overnight delivery label and/or self addressed stamped envelope

         for return of documents

Mailing address for overnight mail:                                    Mailing address for regular mail:

Ohio Secretary of State                                                    Ohio Secretary of State

Attn: Elections Div.                                                           Attn: Elections Div.

180 E. Broad St., 15^th Floor                                            P.P. Box 2828

Columbus, Ohio 43215                                                    Columbus, Ohio 43216