Voters reidentification questionnaire.

The questionnaire to reidentify a voter shall be in substantially the following form:

VOTERS REIDENTIFICATION QUESTIONNAIRE

Date _____, 20

Name _________________________________________

(FIRST) (MIDDLE) (LAST)

Legal Residence Address __________________________________________

STREET

City or Town ___________________________________________________

State _________________________________________________________

Date of Birth _______ Sex _______

I now vote and I am a qualified elector in precinct or Beat No. _____, Box No. _____, Coosa County, and I have not been disqualified from voting in this county. I am not a qualified voter in any other county in the State of Alabama or in any other state in the United States.

I have resided in Precinct or Beat No. ____ for the past _____ months.

Signed _________

Signature of Worker

Sworn and subscribed before me this ____ day of ____, 20_.

Registrar - Judge of Probate

(Acts 1978, No. 864, p. 1290, §9.)