[STATE OF ....
County of ....]
[(name of foreign country and city or other jurisdictional unit)]
I, ...., certify subject to the penalties of s., Wis. Stats., for false statements, that I am a resident of the [.... ward of the] (town) (village) of ...., or of the .... aldermanic district in the city of ...., residing at ....* in said city, the county of ...., state of Wisconsin, and am entitled to vote in the (ward) (election district) at the election to be held on ....; that I am not voting at any other location in this election; that I am unable or unwilling to appear at the polling place in the (ward) (election district) on election day or have changed my residence within the state from one ward or election district to another later than 28 days before the election. I certify that I exhibited the enclosed ballot unmarked to the witness, that I then in (his) (her) presence and in the presence of no other person marked the ballot and enclosed and sealed the same in this envelope in such a manner that no one but myself and any person rendering assistance under s. 6.87(5), Wis. Stats., if I requested assistance, could know how I voted.
Identification serial number, if any: ....
The witness shall execute the following:
I, the undersigned witness, subject to the penalties of s., Wis. Stats., for false statements, certify that I am an adult U.S. citizen** and that the above statements are true and the voting procedure was executed as there stated. I am not a candidate for any office on the enclosed ballot (except in the case of an incumbent municipal clerk). I did not solicit or advise the elector to vote for or against any candidate or measure.
* - An elector who provides an identification serial number issued under s., Wis. Stats., need not provide a street address.
** - An individual who serves as a witness for a military elector or an overseas elector voting absentee, regardless of whether the elector qualifies as a resident of Wisconsin under s., Wis. Stats., need not be a U.S. citizen but must be 18 years of age or older.
*** - If this form is executed before 2 special voting deputies under s., Wis. Stats., both deputies shall witness and sign.
Wis. Stat. § 6.87