I. No challenge may be asserted except in the form of a signed affidavit, under oath administered by an election official, in the following form:
INFORMATION ON THE PERSON MAKING THE CHALLENGE
Name of Person Making the Challenge:

Last Name First Name Middle Name/Initial

Party affiliation

If person making a challenge is a voter: Physical Address-Street Name __ampersand__ Number

If person is a political party or attorney general appointee: mailing address __ampersand__ phone number

The challenger’s qualifications to assert the challenge
INFORMATION ON THE VOTER BEING CHALLENGED: The person making the challenge shall complete the following:
Name being used by the voter who you wish to challenge:

Last Name First Name Middle Name
GROUNDS FOR THE CHALLENGE: The person making the challenge shall indicate the ground on which the challenge is made (check all grounds that apply).
___ The person seeking to vote is not the individual whose name he or she has given
___ The person seeking to vote has already voted in the election at (name polling place) ____________ at approximately (state time if known) __________
___ The person seeking to vote is disqualified as a voter by conviction of a willful violation of the elections laws (state offense, court, and date of conviction)
___ The person seeking to vote is under 18 years of age
___ The person seeking to vote is not a United States Citizen
___ The person seeking to vote is not domiciled in the town or ward where he or she is seeking to vote (state person’s true domicile-town/city)
___ The person seeking to vote does not reside at the address listed for that person on the checklist
___ The person seeking to vote is an incarcerated convicted felon who is currently sentenced to incarceration (state name of institution person is in)
___ This is a primary and the person seeking to vote in the (state political party name) __________ primary is not a declared member of the party he or she claims to be affiliated with
___ The person seeking to vote is ineligible to vote pursuant to the following state or federal statute or constitutional provision:
BASIS FOR THE CHALLENGE: The person making the challenge shall state the specific source of the information or personal knowledge upon which the challenge of the particular individual is based:

OATH: The person making the challenge shall complete the following:
I hereby swear and affirm, under the penalties of perjury, that to the best of my knowledge and belief the information above is true and correct.
____________________
(Signature of challenger)
On the date shown above, before me, __________ (print name of notary public, justice of the peace, election officer), appeared __________ (print name of person whose signature is being notarized), known to me or satisfactorily proven (circle one) to be the person whose name appears above, and he or she subscribed his or her name to the foregoing affidavit and swore that the facts contained in this affidavit are true to the best of his or her knowledge and belief.
____________________
Notary Public/Justice of the Peace/Official Authorized by N.H. Rev. Stat. § 659:30
TO BE COMPLETED BY THE MODERATOR: Ruling on the challenge:
If the ground at issue is age, citizenship, or domicile: The supervisors of the checklist have ruled that the challenged voter is: qualified as a voter; not qualified as a voter.
The moderator rules on challenges based on other grounds. The moderator rules that the challenge is: well grounded; not well grounded. If it is ruled that the voter is not qualified or that the challenge is well grounded, the challenged person may vote only if he or she completes and swears to a challenged voter affidavit.
II. A challenge may be asserted only upon personal knowledge or other basis of probable cause that the challenged voter is ineligible to vote. No challenge may be accepted unless one of the following grounds is asserted and specific facts are offered in support of such grounds:
(a) The person seeking to vote is not the individual whose name he or she has given.
(b) The person seeking to vote has already voted in the election at the time and place specified in the challenge.
(c) The person seeking to vote is disqualified as a voter by conviction of a willful violation of the elections laws, such conviction having been for the offense specified in the challenge.
(d) The person seeking to vote is under 18 years of age.
(e) The person seeking to vote is not a United States citizen.
(f) The person seeking to vote is not domiciled in the town or ward where he or she is seeking to vote because the person’s true domicile is in the town or city specified in the challenge.
(g) The person seeking to vote does not reside at the address listed for that person on the checklist.
(h) The person seeking to vote is an incarcerated convicted felon who is currently sentenced to incarceration in the institution specified in the challenge.
(i) The person is attempting to vote in a primary and the person is not a declared member of the party with which he or she claims to be affiliated.
(j) The person is ineligible to vote pursuant to some other state or federal statute or constitutional provision specified in the challenge.