Indiana Code Title 3. Elections § 3-11-8-23

(1) A statement that the voter is a citizen of the United States.

(2) The voter's date of birth to the best of the voter's information and belief.

(3) A statement that the voter has been a resident of the precinct for thirty (30) days immediately before this election or is qualified to vote in the precinct under IC 3-10-10, IC 3-10-11, or IC 3-10-12.

(4) The voter's name and a statement that the voter is generally known by that name.

(5) A statement that the voter has not voted and will not vote in any other precinct in this election.

(6) The voter's current residential address, including the street or number, and if applicable, the voter's residential address thirty (30) days before the election, and the date the voter moved.

(7) If applicable, that, when the voter was challenged to present proof of identification or an additional document to confirm the voter's identity and current residence, the voter presented proof of identification or the additional documentation that complied with IC 3-5-2-40.5 or IC 3-7-33-4.5.

(8) A statement that the voter understands that making a false statement on the affidavit is punishable under the penalties of perjury.

(9) If the individual's name does not appear on the registration list, a statement that the individual registered to vote and where the individual believes the individual registered to vote during the registration period described by IC 3-7-13-10.