I hereby declare that i am unable to sign my declaration for voting my mail-in ballot without assistance because i am unable to write by reason of my illness or physical disability. I have made or received assistance in making my mark in lieu of my signature.
(Complete address of witness)
(Signature of witness)
I hereby declare that I am a qualified registered elector who has obtained an absentee ballot or mail-in ballot. I further declare that I have not cast my absentee ballot or mail-in ballot, and that instead I remitted my absentee ballot or mail-in ballot to the judge of elections at my polling place to be spoiled and therefore request that my absentee ballot or mail-in ballot be voided.
(Signature of elector)........... (Address of elector)
(Local judge of elections)
25 P.S. § 3150.16