Form Sfn 18440 - Certificate Of Write-In Candidacy President Of The United States Page 2
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4SFN 18440 (11-09) Page 2
NAMES OF PRESIDENTIAL ELECTORS
1. Name
2. Name
3. Name
Street or Route Address
Street or Route Address
Street or Route Address
City
City
City
State
Zip Code
State
Zip Code
State
Zip Code
Check Appropriate Box:
No, I do not have a vice-presidential running mate.
Yes, I do have a vice-presidential running mate and his/her complete name and address follows:
Name of Candidate for Vice President
Street or Route Address
City
State
Zip Code
CERTIFICATE OF ACCEPTANCE / VICE-PRESIDENT OF THE UNITED STATES
INSTRUCTIONS
1.
If the presidential candidate has a vice-presidential running mate, the vice-presidential candidate shall complete this
sworn statement and submit it to the Secretary of State at the same time as the presidential candidate's certificate of
write-in candidacy is submitted to the Secretary of State.
2.
If the presidential candidate has no vice-presidential running mate, this certificate shall not be completed and will not
alter the status of the candidacy of the presidential candidate.
CERTIFICATE OF ACCEPTANCE
Vice-President of the United States
I, ______________________________________________________, being duly sworn, depose and say that I reside at
candidate name
_________________________________________________________, City of ___________________________________,
street or route address
city
_______________________, ___________________________; that I accept being designated the candidate for
state
zip code
Vice-President of the United States with ____________________________________________________ as the candidate
name of presidential candidate
for President of the United States as write-in candidates for President and Vice-President of the United States to be voted
upon at the general election to be held on the _________ day of November, ________.
Signature of vice-presidential candidate
VERIFICATION
State of _________________________
)
) ss.
County of ________________________
)
Subscribed and sworn to before me this _________ day of _____________________________, 20____.
(Notary Seal/Stamp)
Notary Public
My Commission Expires_____________________________________
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