Form 2-E - Declaration Of Candidacy - Party Primary Election For District Office - 2010 Page 2
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2VOTING RESIDENCE
CITY, VILLAGE, OR
DATE OF
SIGNATURE
ADDRESS STREET AND
COUNTY
TOWNSHIP
SIGNING
NUMBER
8.
9.
10.
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12.
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– Must be completed and signed by circulator.
CIRCULATOR STATEMENT
I, _______________________________, declare under penalty of election falsification that I reside at
(Printed Name of Circulator)
the 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.
_______________________________
(Signature of Circulator)
WHOEVER COMMITS ELECTION
WHOEVER COMMITS ELECTION
_______________________________
FALSIFICATION IS GUILTY OF A
FALSIFICATION IS GUILTY OF
(Permanent residence address)
FELONY OF THE FIFTH DEGREE
_______________________________
A FELONY OF THE FIFTH DEGREE
(City or Village, State and Zip Code)
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