"State of West Virginia
County of.....................................
I do solemnly swear (or affirm) that my name is.................................................; that I reside at.............................; and that I am the person listed in the precinct register under this name and at this address.
I understand that knowingly providing false information is a violation of law and subjects me to possible criminal prosecution.
.......................................................
Signature of voter
Subscribed and affirmed before me this...........day of.....................,20....
................................
Name of Election Official
................................
Signature of Election Official".
W. Va. Code § 3-1-34