§ 2-7. Statement of absentee voter.

A. 

When returning his/her absentee ballot, the absentee voter shall submit on a separate sheet of paper, along with his/her sealed absentee ballot, the following statement on a form supplied by the Town Clerk with the absentee ballot:

	STATEMENT OF ABSENTEE VOTER
	I do declare that I am a qualified voter in the above referendum; that I will be unable to appear personally on the day of said special Town referendum because of the reason stated on my application heretofore submitted; 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 special Town referendum, 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 special Town referendum; 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 good conduct granted by the board of parole pursuant to the provisions of the executive 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

B. 

The reverse side of the preprinted statement form shall have printed thereon instructions as to the duties of the voter after the marking of the ballot, which instructions shall include a specific direction stating that the envelope must reach the office of the Town Clerk not later than 5:00 p.m. on the day of the referendum in order that the vote may be canvassed. A person who shall make any material false statement in the statement of absentee voter shall be guilty of a misdemeanor.