Form 2-B - Declaration Of Candidacy - Party Primary Election - 2010 Page 2
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2VOTING RESIDENCE
CITY, VILLAGE,
DATE OF
SIGNATURE
ADDRESS STREET AND
COUNTY
OR TOWNSHIP
SIGNING
NUMBER
9.
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WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE
– Must be completed and signed by circulator.
CIRCULATOR STATEMENT
I, ____________________________, declare under penalty of election falsification that I reside at the
(Printed Name of Circulator)
address appearing below my signature; that I am a member of the ___________________ Party; that I
am the circulator of the foregoing petition containing ________ signatures; that I witnessed the
(Number)
affixing of every signature; that all signers were to the best of my knowledge and belief qualified to
sign; and that every signature is to the best of my knowledge and belief the signature of the person
whose signature it purports to be or of an attorney in fact acting pursuant to section 3501.382 of the
Revised Code.
To be completed by circulator, if applicable:
__________________________________
Name and address of person or entity employing you
(Signature of Circulator)
to circulate this petition paper.
______________________________________
______________________________________
(Permanent residence address)
(Print Name of Employer)
______________________________________
(Street and Number or Rural Route)
(City or Village, State and Zip Code)
(City or Village and Zip Code)
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