County of _______.Nomination paper of ______, candidate for the office of _______.

State of California

County of

⎱
⎰

ss.

SIGNER’S STATEMENT

I, undersigned, am a voter of the County of ______, State of California. I hereby nominate __________, who resides at No. ______, ________ Street, City of ________, County of ______, State of California, as a candidate for the office of _______ to be voted for at the election to be held on the ______ day of ______, 20___. I have not signed the nomination paper of any other candidate for the same office.

Number Signature

Printed Name

Residence

 1.  

 2. 

 3. 

 4. 

 5. 

etc.

CIRCULATOR’S AFFIDAVIT

I, ________, solemnly swear (or affirm) all of the following:

1.That I am 18 years of age or older.

2.That my residence address, including street and number, is
.
  [If no street or number exists, a designation of my residence adequate to readily ascertain its location is
.]

3.That I secured signatures in the County of ______ to the nomination paper of ________ as candidate for the office of ______; that the signatures were obtained between _______, 20__, and ________, 20__; that I saw all the signatures on this section of the nomination paper being signed and that, to the best of my information and belief, each signature is the genuine signature of the person whose name it purports to be.

_____ (Signed) Circulator

Subscribed and sworn to before me this ______ day of ______, 20__.

(SEAL) _____

Notary Public (or other official)