Date: ____________________
QUALIFIED VOTER AFFIDAVIT (Identity, Citizenship, Age)
Name: ______________________________
Name at birth if different: ______________________________
Place of birth: ______________________________
Date of birth: ____________________
Date and Place of Naturalization: ______________________________
Domicile Address: ________________________________________
Mailing Address (if different): ________________________________________
Telephone number (requested but optional) ____________________
Email address (requested but optional) ____________________
I hereby swear and affirm, under the penalties for voting fraud set forth below, that I am not in possession of some or all of the documents necessary to prove my identity, citizenship, and age and that I am the identical person whom I represent myself to be, that I am a duly qualified voter of this town (or ward), that I am a United States citizen, that I am at least 18 years of age as of this date or will be at the next election, and that to the best of my knowledge and belief the information above is true and correct.
(Signature of applicant)
In accordance with RSA 659:34, the penalty for knowingly or purposely providing false information when registering to vote or voting is a class A misdemeanor with a maximum sentence of imprisonment not to exceed one year and a fine not to exceed $2,000. Fraudulently registering to vote or voting is subject to a civil penalty not to exceed $5,000.
On the date shown above, before me, ____________________ (print name of notary public, justice of the peace, election officer), appeared ____________________ (print name of person whose signature is being notarized), (known to me or satisfactorily proven (circle one)) to be the person whose name appears above, and he or she subscribed his or her name to the foregoing affidavit and swore that the facts contained in this affidavit are true to the best of his or her knowledge and belief.
This affidavit was executed for purposes of proving (check all that apply):
[ ] Identity
[ ] Citizenship
[ ] Age
________________________________________
Notary Public/Justice of the Peace/Official Authorized by RSA 659:30
An applicant whose domicile is at an abode of another and whose name is not listed on the document offered as proof of domicile may provide a written statement from a person who is listed as owner, property manager, or tenant on the document that the applicant resides at that address, signed by that person under penalty of voting fraud if false information is provided.
RSA 654:12
1979, 436:1. 1990, 119:8. 1992, 287:6, 7. 1994, 4:3. 1996, 169:1. 2003, 289 : 29 . 2006, 300 : 1 . 2009, 278 : 1 . 2010, 172 : 4 , 5. 2011, 192 : 1 . 2012, 285 : 3 -7. 2014, 260 : 2 -6, eff. July 28, 2014; 319:4, 8, 9, eff. Sept. 30, 2014. 2017, 205 : 5 -9, eff. Sept. 8, 2017; 222:1, 2, eff. July 10, 2017. 2021, 111 : 1 , eff. Sept. 7, 2021.