I hereby declare that the foregoing is a true statement to the best of my knowledge and belief, and I understand that if I make any material false statement in the foregoing statement of application for absentee ballots, I shall be guilty of a misdemeanor.
Date.....................Signature of Voter.............
The date of the election and name of the district shall be printed, and the name of the voter, residence and district shall be written in by the fire district.
STATEMENT OF ABSENTEE VOTER
I do declare that I will have been a citizen of the United States for thirty days, and will be at least eighteen years of age, on the date of the district election; that I will have been a resident of this state and of the district if any, shown on the reverse side of this envelope for thirty days next preceding the said election and that I am or on such date will be, a registered voter of said district; that I will be unable to appear personally on the day of said district election at the polling place of the said district in which I am or will be a qualified voter because of the reason stated on my application heretofore submitted; that I have not qualified, or do I intend to vote, elsewhere than as set forth on the reverse side of this envelope; that I have not received or offered, do not expect to receive, have not paid, offered or promised to pay, contributed, offered or promised to contribute to another to be paid or used, any money or other valuable thing, as a compensation or reward for the giving or withholding of a vote at this district election, and have not made any promise to influence the giving or withholding of any such votes; that I have not made or become directly or indirectly interested in any bet or wager depending upon the result of this district election; and that I have not been convicted of bribery or any infamous crime, or, if so convicted, that I have been pardoned or restored to all the rights of a citizen, without restriction as to the right of suffrage, or received a certificate of relief from disabilities or a certificate of good conduct pursuant to article twenty-three of the correction law removing my disability to register and vote.
I hereby declare that the foregoing is a true statement to the best of my knowledge and belief, and I understand that if I make any material false statement in the foregoing statement of absentee voter, I shall be guilty of a misdemeanor.
Date..............Signature of Voter..................
N.Y. Town Law § 175-B