Remedy for denial of right to vote.

To the Moderator of .... (Polling Place) of .... (Party) I, .... (Name), of .... (Street Address), of the (City) (Town) (Borough) of ...., do hereby state, under penalties of false statement, that (1) I am an elector in said municipality, (2) I am qualified to vote in the primary of said Party being held in said municipality on this date and (3) I have not prior to this time offered myself to vote or voted at said primary. .... (a.m.) (p.m.) (Exact Time of Day) Dated at ...., Connecticut, this .... day of ...., 20... .... (Signature) .... (Address) Received at .... (a.m.) (p.m.) on this .... day of ...., 20.., by .... (Signature), Moderator of .... (Polling Place)