Connecticut General Statutes Title 9. Elections § 9-137. Inner envelope for return of ballot; statement under false statement penalty

Each absentee ballot shall be returned to the municipal clerk, inserted in an inner envelope which shall be capable of being sealed and which shall have printed on its face a form containing the following statements:

“I hereby state under the penalties of false statement in absentee balloting that I am eligible to vote at the primary, election or referendum in the municipality in which this absentee ballot is to be cast and that I expect to be unable to appear at my polling place on the day of such primary, election or referendum for one or more of the following reasons: (1) My active service in the armed forces; (2) my absence from the town in which I am eligible to vote; (3) sickness; (4) physical disability; (5) the tenets of my religion which forbid secular activity on the day of such primary, election or referendum; or (6) my duties as a primary, election or referendum official.

Date ․․․․

․․․․ (Signature)”