The registrar, upon determination that the proof provided by the voter qualifies him or her for confidential registration, must complete a form of affirmation. The form of affirmation should be substantially as follows:

CERTIFICATE OF AFFIRMATION

City or Town

I, name of registrar, do solemnly affirm, that the proof provided to me, state which evidence you have received, qualifies voter number ____ as a confidential voter. The proof provided to me complies with M.G.L. c. 51, § 51A, all other applicable statutes, and with 950 C.M.R. 49.00. Accordingly, I hereby certify that the individual whose name and address correspond to confidential voter number is a legally qualified, registered voter.

_____________________

Name Position

__________ Date