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STATEMENT OF SPECIAL VOTER Pursuant to provisions of Election Law, I hereby certify that I have enclosed my voted ballot, as I am unable to vote in person at my designated polling place, for the following reason: Election Law Section 11-300: It is against my religious scruples to vote at a polling place located in a premise used for religious purposes. (Ballot must be cast in person not earlier than one week before the election and not later than the close of polls on election day) Election Law Section 11-302: My duties as a Board of Elections employee, election inspector, poll clerk, election coordinator, or voting machine custodian/technician require me to be elsewhere. (Ballot to be cast not earlier than two weeks before the election and not later than the close of polls on election day) Election Law Section 11-306: I do hereby swear or affirm that I am a victim of domestic violence, and further that I have left my residence because of such violence, and further that because of the threat of physical or emotional harm to myself or to family or household members, I wish to cast a special ballot. (Ballot must be cast in person not earlier than one week before the election and not later than the close of polls on election day) DATE 20 VOTER Witness to Mark ---PAGE BREAK--- COUNTY OF OFFICIAL SPECIAL BALLOT ENVELOPE VOTER NAME: RESIDENCE ADDRESS CITY/TOWN WARD (if any) ELECTION DISTRICT ASSEMBLY DISTRICT (if TYPE OF ELECTION: PARTY ENROLLMENT SPECIAL DEMOCRATIC INSPECTOR__________ REPUBLICAN INSPECTOR VOTER MUST SIGN AND DATE THE OTHER SIDE OF THIS ENVELOPE