Sec. 9-232a. Remedy for denial of voting rights. Any elector qualified to vote 
and offering to vote at any election, who is denied the right to vote because his name 
has been checked off on the check list in use at his polling place, but who claims that 
he has not in fact voted or offered himself to vote either in person or by absentee ballot, 
shall be permitted to vote upon signing and furnishing to the moderator a statement, 
under penalties of false statement, that he is an elector qualified to vote in that election 
and has neither offered himself to vote nor voted in person or by absentee ballot at said 
election. Such statement shall be in form substantially as follows:
To the Moderator of .... (Polling Place)
      I, .... (Name), of .... (Street Address), of the (City) (Town) (Borough) of .... do hereby 
state, under the penalties of false statement, that (1) I am an elector in said municipality, 
(2) I am qualified to vote in the (State) (City) (Town) (Borough) (Special) election being 
held in said municipality on this date and (3) I have not prior to this time offered myself 
to vote or voted either in person or by absentee ballot at said election.
      .... a.m., p.m. (exact time of day)
      Dated at ...., Connecticut, this .... day of ...., 20...
      .... (Signature)
.... (Address)
      Received at .... (Time) (a.m.) (p.m.) on this .... day of ...., 20.., by, .... (Signature) 
Moderator of .... (Polling Place)
      (February, 1965, P.A. 255, S. 1; 1971, P.A. 871, S. 73.)
      History: 1971 act changed penalty of "perjury" to "false statement" where appearing; (Revisor's note: In 2001 the 
references in this section to the date "19.." were changed editorially by the Revisors to "20.." to reflect the new millennium).