County and precinct number within District: Write-in (5) Political party: Republican (6) Address: County: DC Vote: (7) Total voted: (1,621,534) Write-in candidate s certificate of nomination (WV Code 3-6-4) I hereby swear and affirm that the following information is true: (1) Date of Election: (Check one) Primary May 82012,12 Genera — November 6, 2012 (2) Name of office sought:
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THIS FORM MUST BE COMPLETE IN ORDER TO BE ACCEPTED. READ INSTRUCTIONS CAREFULLY. STATE OF WEST VIRGINIA Write-in Candidate s Certificate of Announcement for 2012 Elections (WV Code 3-6-4a) I hereby
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