Conn. Gen. Stat. § 9-439a
Any elector qualified to vote at any primary and offering so to vote who is denied the right to vote because his name has been checked off on the check list in use at his polling place, but who claims that he has not in fact voted or offered himself to vote, shall be permitted to vote upon signing and furnishing to the moderator a statement, under penalties of false statement, that he has neither offered himself to vote nor voted at said primary. Such statement shall be in form substantially as follows:
To the Moderator of .... (Polling Place) of .... (Party)
I, .... (Name), of .... (Street Address), of the (City) (Town) (Borough) of ...., do hereby state, under penalties of false statement, that (1) I am an elector in said municipality, (2) I am qualified to vote in the primary of said Party being held in said municipality on this date and (3) I have not prior to this time offered myself to vote or voted at said primary.
.... (a.m.) (p.m.) (Exact Time of Day)
Dated at ...., Connecticut, this .... day of ...., 20...
.... (Signature)
.... (Address)
Received at .... (a.m.) (p.m.) on this .... day of ...., 20.., by .... (Signature), Moderator of .... (Polling Place)
Conn. Gen. Stat. § 9-439a
(February, 1965, P.A. 255, S. 2; 1971, P.A. 871, S. 77; P.A. 87-509, S. 20, 24.)