To the SECRETARY OF STATE OF INDIANA OR THE INDIANA ELECTION DIVISION OR THE RELEVANT COUNTY CIRCUIT COURT CLERK: Each of the undersigned represents that: 1) the individual resides at the address by the individual's signature, 2) the individual is a duly qualified registered voter in INDIANA, and 3) the individual desires to be able to vote for the candidate(s) listed below, and each of the undersigned respectfully requests you to place the following names as legally-qualified candidates on the 11/6/2012 General Election Ballot as candidates on the GREEN PARTY ticket.

CANDIDATE 1 Name: Jill Stein
Address: 17 Trotting Horse Dr., Lexington, MA 02421
Office: President of the United States

CANDIDATE 2 Name: Andrew U.D. Straw
Address: 64711 Apple Ridge Rd, Goshen, IN 46526
Office: U.S. House of Representatives, Indiana, District 2

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