19. Upon the said margin of said flap on the inner envelope to be sent to a removed resident there shall be printed a certificate in affidavit form substantially as follows:

State of ……………………

County of ………………….., or (if applicable)

Country of ………………….

I, the undersigned, do hereby certify that:

1. I am a citizen of the United States;

2. I was born on ………………….

(date of birth)

3. I reside at ……………………………………… in

(street and number or R.D. route)

………………………… in ………………………….

(name of city or municipality) (name of county)

County in the State of …………………………… and I have

(name of state, territory, commonwealth, or District of Columbia)

resided at this address since my removal from my former address in New Jersey and expect to continue to reside there until and on the date of said election;

4. I formerly resided at ……………………………….

(street and number or R.D. route)

in ………………………… in ………………………

(name of city or municipality) (name of county)

county in New Jersey and I was registered as a voter, and continued to reside at said address until my removal to my present address;

5. Because of the insufficient period of my residence at my present address, ………………………………………….

I am unable to vote at the election to be held on …………….

(date of election)

but I believe that I am eligible to vote at my former residence in the State of New Jersey for electors for President and Vice-President of the United States at such election.

………………………. Applicant

(SIGNATURE)

………………………. Applicant

(PRINT name here)

L.1964,c.134,s.19; amended 1968,c.238,s.14; 1972,c.30,s.6; 1976,c.24,s.13; 1994,c.77,s.15.