(a) Each absentee ballot shall be accompanied by an envelope upon which shall be printed an affidavit.

(b) With respect to an absentee ballot cast pursuant to Section 17-11-3, the affidavit shall read as follows:

"State of Alabama

County of ___________

I, the undersigned, do swear (or affirm) that:

(1) I am a resident of ___________ County in the State of Alabama.

(3) My voting precinct (or place where I vote) is:_______________

_____________________________________

_____________________________________

(5) I am entitled to vote an absentee ballot because:

Check only one:

___ I will be out of the county or the state on election day.

___ I am physically incapacitated and will not be able to vote in person on election day.

___ I work a required workplace shift which has at least 10 hours which coincide with the polling hours at my regular polling place.

___ I am a student at an educational institution located outside the county of my permanent residence and am therefore unable to vote at my usual polling place on election day.

___ I am a member of or a spouse or dependent of a member of the Armed Forces of the United States or am otherwise entitled to vote pursuant to the federal Uniformed and Overseas Citizens Absentee Voting Act, 42 U.S.C. 1973ff.

___ I have been appointed as an election officer at a polling place which is not my regular polling place.

___ I will be out of the county on election day responding to a state of emergency as declared by this state or any other state, or by the federal government.

I further swear (or affirm) that I have not voted nor will I vote in person in the election to which this ballot pertains.

I have marked the enclosed absentee ballot voluntarily and I have read or had read to me and understand the instructions accompanying this ballot and I have carefully complied with such instructions.

Moreover, I further swear (or affirm) that all of the information given above is true and correct to the best of my knowledge and that I understand that by knowingly giving false information so as to vote illegally by absentee ballot that I shall be guilty of a misdemeanor which is punishable by a fine not to exceed one thousand dollars ($1,000) or confinement in the county jail for not more than six months, or both.

IF YOUR AFFIDAVIT IS NOT SIGNED (OR MARKED), AND IF YOUR AFFIDAVIT IS NOT WITNESSED BY TWO WITNESSES 18 YEARS OF AGE OR OLDER OR A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ACKNOWLEDGE OATHS, PRIOR TO BEING DELIVERED OR MAILED TO THE ABSENTEE ELECTION MANAGER, YOUR BALLOT WILL NOT BE COUNTED.

Sworn to and subscribed before me this _____ day of _____, 2__.

I certify that the affiant is known (or made known) to me to be the identical party he or she claims to be.