Applications for provisional ballots.

(b) If the moderator decides that an elector, whose name appears on the registry list and who has been challenged pursuant to sections 9-232 to 9-232f , inclusive, is not eligible to vote in the primary or election for federal office, such elector may apply for and cast a provisional ballot upon the execution of a written affirmation by the elector at the polling place affirming that the elector is qualified to vote in the election or primary for federal office in the polling place and has neither offered himself to vote nor voted in person or by absentee ballot at said election or primary for federal office at the polling place. (c) Such application for provisional ballot shall be prescribed by the Secretary of the State, executed before an election official and include a written affirmation, under penalty of false statement in absentee balloting pursuant to section 9-359a , which shall be in the form substantially as follows: AFFIRMATION: I, the undersigned, do hereby state, under penalties of false statement, that: 1. I am an elector in the town indicated. 2. I am eligible to vote in the election or primary indicated for federal office today in the town and polling place indicated. 3.a. My name does not appear on the official list of eligible voters for the polling place indicated, and the polling place officials called the registrars of voters and were told that my name did not appear on the active registry list for this town for at least one of the four years previous or on one of the preliminary active registry lists for this year; or b. The moderator decided that I am not eligible to vote for federal office in the town indicated for the reason of disfranchisement, lack of identity, lack of bona fide residence or failure to present the prescribed identification required for new electors after January 1, 2003, indicated. 4. My residence address is located in the voting district that this polling place serves. 5. I have not voted and I will not vote otherwise than by this ballot in person or by absentee ballot at this election or primary for federal office. 6. I apply for a provisional ballot for federal office.