Fillable Printable Form 49024
Fillable Printable Form 49024
Form 49024
INDIANA PETITION FOR PRIMARY BALLOT PLACEMENT AS A CANDIDATE FOR (CAN-4)
UNITED STATES SENATOR IN 2018
State Form 46434 (R13 / 5-17)
Indiana Election Division (IC 3-8-2-8, IC 3-8- 2-9(a))
COUNTY:
INSTRUCTIONS: This petition is used to nominate candidates for placement on the May 8, 2018 Democratic or Republican Primary Election Ballot for the office of United States Senator. Petitioners are not
required to provide precinct and congressional district information. The county voter registration office will complete this information after the petition is filed. Except in cases of disability, the petitioner must
complete this information in the petitioner’s own handwriting. If assistance is provided due to disability, the assister must complete the affidavit on the reverse of this form. Each candidate must also complete a
Declaration of Candidacy for Primary Nomination form (CAN -2). This p etition must be filed w ith the appro priate coun t y voter registration office for proc essing beginnin g Janu ary 10, 2018, an d no later
than NOON, February 6, 2018. Once certified the petition must be filed, along with CAN-2, with the Secretary of State or Indiana Election Division no later than NOON, Feb. 9, 2018.
TO THE SECRETARY OF STATE OF INDIANA OR THE INDIANA ELECTION DIVISION:
Each of the undersigned represents that: 1) the in dividual resides at the address after the individual’s signature, 2) the individual is a duly qualified registered voter in I ndiana, and 3) the individual desires to be
able to vote for the candidates listed below; and each of the undersigned respectfully requests you to place the following names of legally qualified candidates on the May 8, 2018 Primary Election Ballot as
candidates of the (check only one box please)
Democratic Party or Republican Party.
Candidate Name (as established on CAN-2 form) Complete Candidate Address Office Sought
SIGNATURE
PRINTED NAME
First Last
DATE OF
BIRTH
MM/DD/YYYY
RESIDENCE ADDRESS (No P.O. Boxes)
Number Street Apartment
CITY or TOWN & ZIP CODE
Office Use Only
Precinct/Ward
Office Use
Only
Congress
District
1
2
3
4
5
6
7
8
9
10
Petition Carrier Certification
I affirm under the penalties for perjury that I have no reason to believe that any individual whose signature appears on this page is ineligible to sign this petition or did not properly complete and sign this page.
___________________________ ________________________________ ___________________________, ______ __________________________, 20 ___
CARRIER’S SIGNATURE CARRIER’S PRINTED NAME CARRIER’S DATE OF BIRTH (month, day, year) DATE SIGNED BY CARRIER (month, day, year)
__________________________________________________________________________________________________________________
CARRIER’S FULL ADDRESS, INCLUDING ZIP CODE
(number and street, city, state, and ZIP code)
Reset Form
County Voter Registration Office Certification
County: Number of Valid Signatures:
I certify that, in accordance with IC 3-8-2-9, I have reviewed the registration records of the petitioners on this petition and certify the above number to be registered voters of this County.
I also certify the following Congressional Di strict breakdown of petitioners on this petition
who are registered voters:
Number of Voters Congressional District
Witness my/our hand and seal this
_______________ day of
_____________________________, 2018, at
_______________________________, India na.
COUNTY
SEAL HERE
Signature 1
Clerk of the Circuit Court or
Member of the Board of Registration
Signature 2
Member of the Board of Registration
County Voter Registration Office Certification
County: Number of Valid Signatures:
I certify that, in accordance with IC 3-8-2-9, I have reviewed the registration records of the petitioners on this petition and certify the above number to be registered voters of this County.
I also certify the following Congressional Di strict breakdown of petitioners on this petition
who are registered voters:
Number of Voters Congressional District
Witness my/our hand and seal this
_______________ day of
_____________________________, 2018, at
_______________________________, India na.
COUNTY
SEAL HERE
Signature 1
Clerk of the Circuit Court or
Member of the Board of Registration
Signature 2
Member of the Board of Registration
Affidavit of Assistance Provided to Petitioner(s)
I affirm under the penalties for perjury that I assisted the following petitioners, due to disability, in writing the petitioner’s signature, printed name, and residence address on this petition:
Names of Petitioners Assisted by me: ________________________________________________________________________________________________ ___ ___ __ ____________ __ ____________ __ ____________ __ _
_____________ ____________ __ ____________ __ ______, 20_____ _
DATE ASSISTANCE PROVIDED (month, day, year)
_____________________________________ ________________________________ _______________________________________________________________________________________
ASSISTER’S SIGNATURE ASSISTER’S PRINTED NAME ASSISTER’S ADDRESS (number and street, city, state, and ZIP code)
