In the State of Illinois )

                                     )

County of

AFFIDAVIT

I, the undersigned Affiant, do hereby state under penalty of perjury that I have personal knowledge of the
matters stated herein and that if called to testify I would state the same.

* Please fill in as many details as you can provide

1. My name is 

I Reside at

, Illinois

my voterid is

2. On

I

at the voting center or DropBox for

in

located at

3. I hereby declare that I intended to and did indeed make the following selections on my ballot at the time of my vote.

FOR UNITED STATES SENATOR
FOR GOVERNOR & LIEUTENANT GOVERNOR
FOR ATTORNEY GENERAL
FOR SECRETARY OF STATE
FOR JUDGE OF THE SUPREME COURT 2ND JUDICIAL DISTRICT
FOR (KANE) COUNTY CLERK

* May not apply to your ballot

* May not apply to your ballot

FURTHER AFFIANT SAYETH NOT

Under penalties as provided by the law pursuant to Section 1-109 of Illinois Code of Civil  Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except  as to matters therein stated to be information and belief, and as to such matters the undersigned certifies as  aforesaid that he/she verily believes the same to be true. 

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