(c) A certificate in substantially the following form must be printed on the reverse side of the official carrier envelope in a manner that requires the voter to sign across the flap of the envelope:
"I certify that the enclosed ballot expresses my wishes independent of any dictation or undue persuasion by any person.
________________________________
Signature of voter
By: ____________________________
Signature of person assisting
voter, if applicable (see Ballot
Envelope for restrictions and
penalties)
_______________________________
Printed name of person assisting
voter, if applicable
_______________________________
Residence address of person
assisting voter, if applicable"