............................................................................... | ............................................................................... |
(Date) | (Mark) |
............................................................................... | ............................................................................... |
(Complete Address of Witness) | (Signature of Witness) |
I hereby declare that I am a qualified registered elector who has obtained an absentee ballot or mail-in ballot. I further declare that I have not cast my absentee ballot or mail-in ballot, and that instead I remitted my absentee ballot or mail-in ballot and the envelope containing the declaration of the elector to the judge of elections at my polling place to be spoiled and therefore request that my absentee ballot or mail-in ballot be voided.
(Date)
(Signature of elector)................ (Address of elector)
(Local judge of elections)
25 P.S. § 3146.6