(2) Prior to voting the provisional ballot, the elector shall be required to sign an affidavit stating the following:
I do solemnly swear or affirm that my name is __________, that my date of birth is __________, and at the time that I registered I resided at __________ in the municipality of __________ in __________ County of the Commonwealth of Pennsylvania and that this is the only ballot that I cast in this election.
Signature of Voter/Elector
Current Address
Check the Reason for Casting the Provisional Ballot.
Signed by Judge of Elections and minority inspector