Remedy for denial of voting rights.

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)