AFFIDAVIT - SAMPLE - State of Indiana

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I, [Person’s Name], am a resident and registered voter of the [City/Town/Township] of ________________, County of [Name of County], State of Indiana, and do hereby certify, swear or affirm under the penalty of perjury that I am competent to give the following declaration based on my personal knowledge, and that the following statement is true and correct to the best of my knowledge:

Each signature on [OR: “pages ____ through ____ of”] this petition was affixed in my presence and is the true signature of the individual who signed the petition.

Further the affiant saith naught.

______________________________ _____________________________ _________________

(Print Name) (Sign Name)(Date)


) SS:

COUNTY OF ____________)

Before me, a Notary Public in and for said County and State, hereby certify that ______________________________, personally known to me to be the affiant in the foregoing affidavit, personally appeared before me this day and having been by me duly sworn deposes and says that the facts set forth in the above affidavit are true and correct.

Witness my hand and official seal this the _________ day of __________, _________.




Printed Name

____________________________________ County of Residence


Commission Expiration Date

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