In determining the requirements for an overseas voter certificate, the committee and the Secretary of State shall consider including information including the following:
"OVERSEAS VOTER CERTIFICATE
"I, ______________ (print name), swear or affirm, under penalty of perjury, that:
"1. I am a member of the uniformed services or Merchant Marine on active duty temporarily residing outside the United States; or the eligible spouse or dependent of such a member temporarily residing outside the United States; or a United States citizen temporarily residing outside the United States; and
"2. I am a United States citizen, at least 18 years of age, as of the date of the applicable election, and eligible to vote in the requested jurisdiction; and
"3. I have not been convicted of a disqualifying felony or been adjudicated mentally incompetent or, if I have, my voting rights have been reinstated; and
"4. I am not registering, requesting a ballot, or voting in any other jurisdiction in the United States, except the jurisdiction cited in this voting form.
"In voting, I have marked and sealed my ballot in private and have not allowed any person to observe my marking of the ballot, except for those authorized to assist overseas voters under state or federal law. I have not been influenced in marking my ballot. My signature and date below indicate when I completed this certificate. The information on this form is true, accurate, and complete to the best of my knowledge. I understand that a material misstatement of fact in completion of this document may constitute grounds for a conviction for perjury.
"Signed: ________________ Date: _____"