Form of Certificate

The certificate of confidential registration must contain the signatures ofa majorityofthe board of registrars (a facsimile stamp may be used). Where applicable, the town seal shall also be affixed to the certificate. The form of the certificate should be substantially as follows: CONFIDENTIAL REGISTRATION Name of City or Town Valid only for: Election Date Registration number Polling Location (Seal of Town) (if applicable) Signatures of Registrars Name Name Name This certificate must be brought with you to the polling location identified above whenyougo to vote. NOTE TO CERTIFICATE HOLDER: Please be aware that your confidential voter registration may expire if certain conditions are not met. If you have received confidential registration because: ° you have a court order granting protection, it will expire 60 days from the date when the court order expires, unless you provide the registrar with proof that the court order has been extended; ° you are a resident in a shelter, it will expire one year and 60 days from the date on the shelter director’s letter confirming residency, unless you provide the registrar with a new letter from the director of the shelter. WARNING TO ELECTION OFFICERS: The name and address of this confidential voter are not a public record and should not be announced even if you recognize this person. A primary or election officer who makes any statement or gives any information in regard to a confidential registration certificate shallbe punished by a fine of not more than $500.00 or by imprisonment for not more than one year. M.G.L. c. 56, § 14.