California Code, Elections Code - ELEC § 6586

County of _______________. Nomination paper of a presidential preference candidate for the American Independent Party presidential primary ballot.

State of California

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ss.

County of ____________

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    I, the undersigned, am a voter of the County of ____________________, State of California, and am registered as intending to affiliate with the American Independent Party. I hereby nominate __________ for the presidential preference portion of the American Independent Party's presidential primary ballot, to be voted for at the presidential primary to be held on the __________ day of __________, 20___. I have not signed the nomination paper of any other candidate for the same office, or for any group of delegates, to the national convention of the party, and I further declare that I intend to support the candidate named herein.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Number

Signature

Printed name

Residence

1.

_________________________________________________________________________________________

2.

_________________________________________________________________________________________

3.

_________________________________________________________________________________________

etc.

_________________________________________________________________________________________

    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 a candidate in the presidential preference primary of the American Independent Party; that all the signatures on this section of the nomination paper numbered from 1 to ___, inclusive, were made in my presence, that the signatures were obtained between ______, 20___, and ______, 20___, and that to the best of my knowledge and belief each signature is the genuine signature of the person whose name it purports to be.

    I declare under penalty of perjury that the foregoing is true and correct.

(Signed) __________________________________________________