Can-37 - Declaration Of Candidacy For Precinct Committeeman Or State Convention Delegate

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(CAN-37)

DECLARATION OF CANDIDACY FOR PRECINCT COMMITTEEMAN OR

IN 2016

STATE CONVENTION DELEGATE

State Form 47417 (R11 / 9-15)

Indiana Election Division (IC 3-8-1-32; IC 3-8-2-7)

INSTRUCTIONS: This form is used by Democratic and Republican Party candidates for Precinct Committeeman and State Convention

Delegate. A declaration of candidacy for election as a precinct committeeman or state convention delegate must be filed with the county election board

or Lake or Tippecanoe County boards of elections and registration no earlier than January 6, 2016 and no later than noon, February 5, 2016.

If running for BOTH precinct committeeman and state convention delegate, complete a separate copy of the CAN-37 for each office.

STATE OF INDIANA

)

COUNTY OF ___________________________________

)

GENERAL INFORMATION

I, ____________________________________________________________________________ the undersigned, certify the following:

Name of Candidate

(1) I am a registered voter of Precinct _____________________ of the Township of _______________________________________,

(or of Ward _____________ of the City or Town of ______________________), County of _____________________, State of Indiana.

(2) I reside in the ________________________ Congressional district.

(3) I request that my name be placed on the May 3, 2016 primary ballot of the party with which I am affiliated:

(check one)

Democratic Party or

Republican Party

for the office of

Precinct Committeeman OR

State Convention Delegate (check only one office on this copy)

Precinct Name _____________________________ or Convention Delegate District/“At Large” _____________________________

(4) I comply with all requirements under the laws of the State of Indiana and any candidate requirements set by my party’s rules to be a candidate for this

office.

RESIDENCY INFORMATION

(5) My complete residence address is:

_________________________________________________________

___________________________, Indiana _______________

Complete Residence Address Must Be Inserted

City

ZIP Code

(6) My mailing address is (if different from residence address):

_________________________________________________________

___________________________, Indiana _______________

Mailing Address (Write “SAME” if both addresses are identical or leave blank)

City

ZIP Code

CANDIDATE NAME INFORMATION

I request that my name appear on the primary election ballot in the following manner:

____________________________________________________________________________________________________________

(Include any Nickname and/or Suffix, Jr. Sr. II III IV)

I also request that my name on my voter registration record be the same as the name on this declaration of candidacy.

The candidate’s name must comply with the requirements in Indiana Code 3-5-7. If a candidate’s name does not comply with this state law, the declaration may be

challenged under Indiana Code 3-8-1-2.

*A candidate may use a nickname on the ballot only if the nickname is a name by which the candidate is commonly known and does not exceed 20 characters.

EXAMPLE: John R. (Jack) Doe A candidate may not use a title or degree as a designation or a designation that implies a title or degree.

CERTIFICATION

I, the undersigned, certify that the information in this Declaration of Candidacy is true and complete, and that I meet the specific requirements of this office.

______________________________________ ______/______/_______ (_______)_______________

(_______)_____________

Signature

Date signed (MM/DD/YY)

Telephone (Day)

Telephone (Evening)

STATE OF __________________________________

)

COUNTY OF ________________________________

)

Subscribed and sworn to before me this ________ day of _____________________________, 2016.

________________________________________________________________________________