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(Date)
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(Mark)
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(Name of Voter)
"I, the undersigned, hereby certify that the above named voter affixed their mark to this application in my presence and I know them to be the person who affixed their mark to said application and understand that this statement will be accepted for all purposes as the equivalent of an affidavit and if it contains a material false statement, shall subject me to the same penalties as if I had been duly sworn."
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(Signature of Witness)
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(Address of Witness)
Such statement shall be included in the application blank form furnished by the village clerk.
N.Y. Elec. Law § 15-119