OFFICIAL BALLOT, SPECIAL PRESIDENTIAL VOTERS,
FOR GENERAL ELECTION,
NOVEMBER......., 20....
Name of voter ..........................................................
Residence from which vote is being cast:
Street and number ......................................................
City or town ...........................................................
County .................................................................
Assembly District or Ward ..............................................
Election District ......................................................
The date of the election and name of the county shall be printed, and the name of the voter, residence, name of the city or town, number of ward or assembly district, if any, and election district shall be printed, written or stamped in by the board.
STATEMENT OF SPECIAL PRESIDENTIAL VOTER
I do declare I am a qualified special presidential voter of said district; that I am not qualified and am not able to qualify to vote elsewhere than as set forth on the reverse side of this envelope; that I am a citizen of the United States; that on the date of the election for which this ballot is voted, I will be at least eighteen years of age; and that I have not committed any act, nor am I under any impediment, which denies me the right to 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, I shall be guilty of a misdemeanor.
Date.................20..... .....................................
Signature or mark of voter
.....................................
Signature of Witness (required only if voter does not sign his or her own name)
.....................................
Address of Witness
N.Y. Elec. Law § 7-125