2012 Connecticut General Statutes
Title 9 - Elections
Chapter 145 - Absentee Voting
Section 9-158d - *(See end of section for amended version of subsection (a) and effective date.) Application form.

*(a) The application for a presidential ballot shall be a form signed in duplicate by the applicant under penalty of false statement in absentee balloting, which shall provide substantially as follows:

To the Town Clerk of the Town of ...., Connecticut

I, the undersigned, declare under penalty of false statement in absentee balloting that the following statements are true:

1. I am a citizen of the United States.

2. I have not forfeited my electoral privileges because of conviction of a disfranchising crime.

3. I was born on ...., and on the day of the next presidential election, I shall be at least 18 years of age. Check and complete 4 or 5, whichever applies:

4. RESIDENT. I am a bona fide resident of the above town, to which I am making this application, and I reside at .... Street. I moved to said town on the .... day of ...., 20... Before becoming a resident of said town, I resided at .... Street, in the Town of .... County of ...., State of ....

5. FORMER RESIDENT. I am a former resident of the above town, to which I am making this application, and resided at .... Street therein. I moved from such town to my present town of residence on the .... day of ...., 20.., being within thirty days before the date of the next presidential election, and for that reason I cannot register to vote in said presidential election in my present town of residence. I am now a bona fide resident of the Town of ...., in the state of ...., now residing at .... Street therein.

6. I hereby apply for a “presidential ballot” for the election to be held on ...., 20... I have not voted and will not vote otherwise than by this ballot at that election. I am not eligible to vote for electors of President and Vice-President in any other town in Connecticut or in any other state.

7. The said ballot is to be given to me personally mailed to me at

.... (bona fide mailing address)

Dated at ...., this .... day of .... 20...

.... (Signature of applicant)

(b) The application for an overseas ballot shall be the federal application permitted under section 9-153a or a form signed by the applicant under penalty of false statement in absentee balloting which shall provide substantially as follows:

To the Town Clerk of the Town of ...., Connecticut

I, the undersigned, declare under penalty of false statement in absentee balloting that the following statements are true:

1. I am a citizen of the United States.

2. I have not forfeited my electoral privileges because of conviction of a disfranchising crime.

3. I was born on ...., and on the day of the next federal election, I shall be at least eighteen years of age.

4. I was a resident of the above town, to which I am making this application, and resided at no. .... Street therein. I moved from such town to my present residence on the .... day of ...., 20... I now reside in ...., at no. .... Street therein.

5. I have a valid passport or card of identity and registration issued under the authority of the Secretary of State of the United States or alternate form of identification.

	(  ) Primary
6. I hereby apply for an overseas ballot for the	(  ) General Election
	(  ) Special Election

to be held on ...., 20... I do not maintain a domicile in any other state or election district of any state or territory or any territory or possession of the United States. I have not voted and will not vote otherwise than by this ballot at such election or primary for which I now apply for an overseas ballot. I am not eligible to vote in any town in Connecticut or in any other state or election district of any state or territory or any territory or possession of the United States.

7. The said ballot is to be mailed to me at ....

.... (Mailing address)

Dated at ...., this .... day of ...., 20...

.... (Signature of applicant)

(1972, P.A. 196, S. 4; P.A. 82-247, S. 5; P.A. 86-179, S. 31, 53; P.A. 87-382, S. 15, 55; P.A. 89-297, S. 9, 18; P.A. 93-384, S. 24, 28; P.A. 97-154, S. 7, 27.)

*Note: On and after July 1, 2013, subsection (a) of this section, as amended by section 6 of public act 12-56, is to read as follows:

“(a) The application for a presidential ballot shall be a form signed in duplicate by the applicant under penalty of false statement in absentee balloting, which shall provide substantially as follows:

To the Town Clerk of the Town of ...., Connecticut

I, the undersigned, declare under penalty of false statement in absentee balloting that the following statements are true:

1. I am a citizen of the United States.

2. I have not forfeited my electoral privileges because of conviction of a disfranchising crime.

3. I was born on ...., and on the day of the next presidential election, I shall be at least 18 years of age.

4. FORMER RESIDENT. I am a former resident of the above town, to which I am making this application, and resided at .... Street therein. I moved from such town to my present town and state of residence on the .... day of ...., 20.., being within thirty days before the date of the next presidential election, and for that reason I cannot register to vote in said presidential election in my present town and state of residence. I am now a bona fide resident of the Town of ...., in the state of ...., now residing at .... Street therein.

5. I hereby apply for a “presidential ballot” for the election to be held on ...., 20... I have not voted and will not vote otherwise than by this ballot at that election. I am not eligible to vote for electors of President and Vice-President in any other state.

6. The said ballot is to be given to me personally mailed to me at

.... (bona fide mailing address)

Dated at ...., this .... day of .... 20...

.... (Signature of applicant)”

(1972, P.A. 196, S. 4; P.A. 82-247, S. 5; P.A. 86-179, S. 31, 53; P.A. 87-382, S. 15, 55; P.A. 89-297, S. 9, 18; P.A. 93-384, S. 24, 28; P.A. 97-154, S. 7, 27; P.A. 12-56, S. 6.)

History: P.A. 82-247 deleted references to absentee elector; P.A. 86-179 made technical changes and added subsection re application for overseas ballot; P.A. 87-382, in sentence 4. of Subsec. (b) substituted “was” for “am” and deleted “former”; P.A. 89-297 deleted statement in Subsec. (b) that applicant does not maintain a domicile “in this state”; P.A. 93-384 amended Subsec. (b) to authorize application to be “a form signed by the applicant under penalty of false statement in absentee balloting” instead of “in the form of an affidavit subscribed and sworn to before an officer authorized to administer oaths” and deleted provision listing persons authorized to administer oaths and the part of the form to be subscribed by administering officer, effective January 1, 1994; P.A. 97-154 amended Subsec. (a) by providing for application to be signed by applicant under penalty of false statement in absentee balloting instead of sworn to by applicant, and deleting certain provisions re oaths, effective July 1, 1997; (Revisor’s note: In 2001 the references in this section to the date “19..” were changed editorially by the Revisors to “20..” to reflect the new millennium); P.A. 12-56 amended Subsec. (a) by deleting provision in statement 3. re completion of statement 4. or 5., deleting former statement 4. re resident, redesignating existing statements 5. to 7. as statements 4. to 6., adding references to state of residence in redesignated statement 4. and deleting reference to any other town in Connecticut in redesignated statement 5., effective July 1, 2013.