STATE OF ______ |
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COUNTY OF ______ |
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I do solemnly swear (or affirm) that my name is ______; that my date of birth is ______; that the last four digits of my Social Security Number are ______; that I am registered to vote in ______ County or City (if a City not within a County), Missouri; that I am a qualified voter of said County (or City not within a County); that I am eligible to vote at this polling place; and that I have not voted in this election. |
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I understand that if the above-provided information is not correct and the election authority determines that I am not registered and eligible to vote, my vote will not be counted. I further understand that knowingly providing false information is a violation of law and subjects me to possible criminal prosecution. |
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__________________ |
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(Signature of Voter) |
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__________________ |
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(Current Address) |
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Subscribed and affirmed before me this ______ day of ______, 20______ |
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__________________ |
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(Signature of Election Official) |
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The voter may provide additional information to further assist the election authority in determining eligibility, including the place and date the voter registered to vote, if known.
§ 115.430, RSMo