Declaration
Of the need of Assistance to Vote
I ___________________________________________________________________________________
(Print name and residential address of elector requiring assistance)
by reason of _________________________________________________ am unable to vote without the
(Print reason for need of assistance)
assistance of ________________________________________________________________________.
(Print name and address of person rendering assistance)
__________________________________________
Date: ___________________________
Signature or mark of elector
WITNESSED BY:
____________________________________________
Signature of Witness
____________________________________________
Signature of Judge of Elections