The questionnaire to reidentify a voter shall be in substantially the following form:
VOTERS REIDENTIFICATION QUESTIONNAIRE
Date _____, 20
(FIRST) (MIDDLE) (LAST)
Legal Residence Address __________________________________________
City or Town ___________________________________________________
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.
Signature of Worker
Sworn and subscribed before me this ____ day of ____, 20_.
Registrar - Judge of Probate