Voter Affidavit

State of New York )

County of __________ )

Town of __________ )

__________ Fire District )

__________, being duly sworn, deposes and says under penalty of perjury:

1. That I reside in the __________ Fire District.

2. I am registered to vote with the __________ County Board of Elections, and I was registered to vote on or before November ___, 20___.

3. I understand that the vote that I have cast will be counted in the General Election of the __________ Fire District on December ___, 20___...