BALLOT FOR MILITARY VOTER
AFFIRMATION
I swear or affirm that:
(a) I am a member of the uniformed services or merchant marine on active duty or an eligible spouse, parent, child or dependent of such a member, and
(b) I am a United States citizen, at least eighteen years of age (or will be by the day of the election), eligible to vote in the requested jurisdiction, and
(c) I have neither been convicted of a felony or other disqualifying offense nor been adjudicated mentally incompetent, or if so, my voting rights have been reinstated, and
(d) I am not registering, requesting a ballot, or voting in any other jurisdiction in the United States, and
(e) My signature and date below indicate when I completed this document, and
(f) The information on this form is true and complete to the best of my knowledge.
I understand that a material misstatement of fact in the completion of this document may constitute grounds for conviction of a crime.
Date .......... 20....
...............................
Signature or mark of voter
...............................
Signature of Witness (required only if voter does not sign his or her own name)
...............................
Address of Witness
TO BE FILLED IN BY THE BOARD OF ELECTIONS:
FOR..........ELECTION......... 20......
County of................................................................
Name of voter............................................................
Voting residence (street and number, if any).............................
City (or town) of..............Ward......................................
Assembly District..............Election District.........................
Party Enrollment (in case of primary election)...........................
IMPORTANT TO MILITARY VOTER: YOU MUST SIGN THE AFFIRMATION ON THIS ENVELOPE.
This ballot was mailed on _________ which is not later than the
(date) day before the election. _______________ _____________ Signed (Witness) Date
N.Y. Elec. Law § 7-123