Any elector qualified to vote and offering to vote at any election, who is denied the right to vote because his name has been checked off on the check list in use at his polling place, but who claims that he has not in fact voted or offered himself to vote either in person or by absentee ballot, shall be permitted to vote upon signing and furnishing to the moderator a statement, under penalties of false statement, that he is an elector qualified to vote in that election and has neither offered himself to vote nor voted in person or by absentee ballot at said election. Such statement shall be in form substantially as follows:

To the Moderator of …. (Polling Place)

I, …. (Name), of …. (Street Address), of the (City) (Town) (Borough) of …. do hereby state, under the penalties of false statement, that (1) I am an elector in said municipality, (2) I am qualified to vote in the (State) (City) (Town) (Borough) (Special) election being held in said municipality on this date and (3) I have not prior to this time offered myself to vote or voted either in person or by absentee ballot at said election.

…. a.m., p.m. (exact time of day)

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

…. (Signature)

…. (Address)

Received at …. (Time) (a.m.) (p.m.) on this …. day of …., 20.., by, …. (Signature) Moderator of …. (Polling Place)