(a) I am a member of the uniformed services or merchant marine on active duty or an eligible spouse, parent, child or dependent of such a member, and

(b) I am a United States citizen, at least eighteen years of age (or will be by the day of the election), eligible to vote in the requested jurisdiction, and

(c) I have neither been convicted of a felony or other disqualifying offense nor been adjudicated mentally incompetent, or if so, my voting rights have been reinstated, and

(d) I am not registering, requesting a ballot, or voting in any other jurisdiction in the United States, and

(e) My signature and date below indicate when I completed this document, and

(f) The information on this form is true and complete to the best of my knowledge. I understand that a material misstatement of fact in the completion of this document may constitute grounds for conviction of a crime. 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 4. On the reverse side of the inner affirmation envelope shall be printed: TO BE FILLED IN BY THE BOARD OF ELECTIONS: FOR..........ELECTION......... 20...... County of................................................................ Name of voter............................................................ Voting residence (street and number, if any)............................. City (or town) of..............Ward...................................... Assembly District..............Election District......................... Party Enrollment (in case of primary election)........................... IMPORTANT TO MILITARY VOTER: YOU MUST SIGN THE AFFIRMATION ON THIS ENVELOPE. 5. The information in subdivision four of this section shall be filled in by the board of elections prior to the mailing of any military ballot and envelopes if the military voter's preferred method of transmission with the board of elections is by mail, or it may be filled in by the board of elections upon the receipt of the returned military ballot and envelope where the ballot and envelope have been transmitted to the military voter other than by mail or in person. 6. The inner affirmation envelope, if delivered by mail or in person, shall be gummed and ready for sealing. Such envelope, or any created by the military voter who has received his or her ballot by facsimile transmission or electronic mail in accordance with the provisions of subdivision seven of this section, shall have printed thereon, on the side opposite the affirmation, instructions as to the duties of the military voter after the marking of the ballot. Such instructions shall include specific directions stating that the ballot must be returned in person or mailed to the appropriate board of elections, when the outer envelope must be postmarked, if mailed, and when such envelope, whether returned in person or mailed, must reach such board of elections in order to be canvassed. Such inner affirmation envelope shall also include a direction that an application for a military ballot should not be enclosed in the inner affirmation envelope containing such ballot. 7. If a military voter has designated a preference to receive his or her ballot by facsimile transmission or electronic mail pursuant to section 10-107 of this chapter, the transmission of the military voter's ballot shall include, together with all information and instructional materials that accompany ballot materials sent by the board of elections to other absentee voters, appropriate instructions as to the folding of same so as to create an inner affirmation envelope containing all of the information set forth in subdivisions three, four and six of this section. 8. Such inner affirmation envelope containing the military ballot shall be enclosed in an outer envelope, addressed to the appropriate board of elections, and bearing on it the words "Official Election Ballot--Via Air Mail". The outer envelope shall include specific directions that if an original completed application for a military ballot has not already been returned in person or mailed to the military voter's board of elections, such application must be completed by the military voter and returned in the outer envelope with the sealed inner affirmation envelope containing the military ballot within the time limits for the receipt of the military ballot itself. Such envelope shall provide lines in the upper left corner for the military voter to write his or her name and complete military address. 9. The outer envelope addressed to the appropriate board of elections and the inner affirmation envelope which contains the ballot shall be mailed to the military voter in a third envelope on which is printed the words "Official Election Ballot--Via Air Mail". 10. At the side opposite the address on the outer envelope, below the gummed seal, for a ballot delivered by mail or in person, or below the flap for a ballot transmitted to the military voter by facsimile transmission or electronic mail, shall be printed: This ballot was mailed on _________ which is not later than the

(date) day before the election. _______________ _____________ Signed (Witness) Date 11. If the military voter's preferred method of transmission is facsimile transmission or electronic mail, the electronic transmittal of the military voter's ballot materials shall include appropriate instructions as to the folding of same so as to create an outer envelope containing all of the information set forth in subdivisions eight and ten of this section.