California Code, Elections Code - ELEC § 6857

Section______________________________ Page______________________________

County of______________________________.

State of California

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ss.

County of____________________

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SIGNER'S STATEMENT

I, the undersigned, am a voter of the County of ______________________________, State of California, and am registered as preferring the Green Party. I hereby nominate ______________________________ for the presidential preference portion of the Green Party's presidential primary ballot, to be voted for at the presidential preference primary 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.

_____________________________________________________________________________________________

etc.

CIRCULATOR'S DECLARATION

I, ____________________, affirm all of the following:

1.

That I am 18 years of age or older.

2.

That my residence address, including street 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 Green 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.

Executed at _______________, California, this _______day of _______, 20__.

[Signed] ________________________________________________________________________________________

Circulator

[Printed Name] __________________________________________________________________________________