Connecticut General Statutes Title 9. Elections § 9-31b. Application form

(1) My name is ․․․․․․․․․․․․․․․․․․․․․․․․ (last name) (first name) (initial).

(2) My bona fide residence is ․․․․․․․․․․․․․․․․․․․․․․․․ (street and number), but I am presently residing at ․․․․․․․․․․․․․․․․․․․․․․․․ (street, number and town if different from residence above).

(3) I am a permanently physically disabled person and my permanent physical disability prevents me and will continue to prevent me from appearing in person at your office.

(4) I am a United States Citizen who has attained the age of eighteen and my electoral privileges are not forfeited by reason of conviction of any disfranchising crime.

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