CANDIDATE PETITION Notes:-All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. I, the undersigned, a registered voter (Print name as it appears on your voter information card) in said state and county, petition to have the name of placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] Nonpartisan No party affiliation ____________________________________________ Party candidate for the office of _____________________________________________________________________________________ (Insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or (month/day/year) Voter Registration Number Street Address City County State Zip Code Signature of Voter Date Signed (month/day/year) [to be completed by Voter] Rule 1S-2.045, F.A.C. DS-DE 104 (Eff. 10/10)

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