Form 4-E - Minor Political Party - Nominating Petition And Statement Of Candidacy Page 2
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2Voting Residence
City, Village, or
Date of
Signature
County
Street Number and Address
Township
Signing
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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 the circulator.
I,
, declare under penalty of election falsification that I reside at the address
Printed Name of Circulator
signatures;
appearing below my signature; that I am the circulator of the foregoing petition containing
Number
that I witnessed the 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
Zip Code
To be completed by the circulator, if applicable: Name and address of person or entity employing you to
circulate this petition paper.
Print Name of Employer
Street Number and Address
City or Village
State
Zip Code
(or rural route and number)
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