Form 2-C - Declaration Of Candidacy - Party Primary Election - 2010 Page 2
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2VOTING RESIDENCE
CITY, VILLAGE, OR
DATE OF
SIGNATURE
ADDRESS STREET
COUNTY
TOWNSHIP
SIGNING
AND NUMBER
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WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE
CIRCULATOR STATEMENT –
Must be completed and signed by circulator.
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.
__________________________________
(Signature of Circulator)
__________________________________
(Permanent residence address)
__________________________________
(City or Village, State and Zip Code)
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