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Precinct Delegate Affidavit of Identity and Receipt of Filing instructions When to file All affidavits must be received by the filing deadline on the date and time specified at Michigan.gov/elections. Affidavits received after the deadline will be rejected regardless of postmark. Where to file File with the county clerk. Withdrawing your filing The deadline for withdrawing is three days after the filing deadline. Once filed, an affidavit of identity may not be altered. If changes are needed, an entirely new affidavit must be filed. Completing the form Section 1: Candidate information Section one requires you to provide your information. You may provide a mailing address to receive your ballot proof and other information at an alternate address. Please provide a phone number and email address so your filing official may contact you. If you are using a name that was not provided to you at birth, you must check the box and provide your former name. However, you do not need to provide a former name if your name changed due to marriage or divorce, or formally for any reason more than 10 years ago, or if you are using your common law name. Section 2: Office sought and ballot information Section two requires detailed information for the office you seek. All office details are required. • First, provide the name of the office you seek as well as the jurisdiction, and precinct number. • Next, check the box stating you are running for a partisan office and list which political party. • Third, provide the date of the primary election. • Fourth, indicate exactly how you want your name to appear on the ballot using upper and lowercase letters. You may not use nicknames or titles (e.g. Dr., PhD, etc). Section 3: Certification and attestation You must mark the box to certify that you are a U.S. citizen and meet the statutory and constitutional requirements for the office sought. Finally, sign and date the affidavit in front of a notary and complete the notarization. Precinct Delegate Affidavit of Identity and Receipt of Filing (Rev. 04/25) 1 ---PAGE BREAK--- Precinct Delegate Affidavit of Identity and Receipt of Filing SECTION 1 Candidate information First name Middle name Last name Year of birth My name has formally changed in the last 10 years for a reason other than marriage or divorce. My former name is Residential address City ZIP Mailing address, if different than above City ZIP Phone number Email Campaign website, if applicable SECTION 2 Office & ballot information Office name Precinct Delegate Jurisdiction Precinct number I am running for a partisan office, and my political party is: Primary election date (mm/dd/yyyy) Indicate exactly how you want your name to be printed on the ballot (use upper and lowercase letters) SECTION 3 Certification & attestation I certify that I am a United States citizen and I meet the statutory and constitutional requirements for the office sought. By signing, I acknowledge that making a false statement in this affidavit is perjury – a felony punishable by a fine up to $1,000 or imprisonment for up to five years or both and may result in disqualification from the ballot. Candidate signature Date Notary signature Notary name County of commission Acting in the County of My commission expires date (mm/dd/yyyy) Date of notarization date (mm/dd/yyyy) Precinct Delegate Affidavit of Identity and Receipt of Filing (Rev. 04/25) 2 Office use only Date of filing Received by Reviewed by CLEAR FORM