Indiana Election Division 36186 Petition of Nomination User Guide

Indiana Election Division 36186 Petition of Nomination

State Form 36186 (R23 / 6-23) Indiana Election Division (IC 3-8-6-5; IC 3-8-6-6(b); IC 3-6-12)

INSTRUCTIONS

This petition is used to nominate independent candidates or candidates of a minor political party. Petitioners are not required to provide precinct and ward information. Except in cases of disability, the petitioner must complete this information in the petitioner’s handwriting. If assistance is provided due to disability, the assistant must complete the affidavit on the reverse of this form. This petition must be filed with the appropriate county voter registration office for processing not earlier than January 10, 2024 and not later than NOON, July 1, 2024. Each candidate must also file a Candidate’s Consent form (CAN-20), original certified petitions, and file-stamped copy of the statement of economic interests with the Indiana Secretary of State or Indiana Election Division not later than NOON, July 15, 2024. Candidates for county-level judge or prosecuting attorney should use this form, not the CAN-21. Candidates for other Local Offices should use a CAN-21 form, not this form. School Board Candidates should use a CAN-34 form, not this form. Presidential Candidates must complete the certification of presidential elector candidates on the reverse.

TO THE SECRETARY OF STATE OF INDIANA OR THE INDIANA ELECTION DIVISION : Each of the undersigned represents that: 1) the individual resides at the address after the individual’s signature at the time this petition was processed by county voter registration officials; 2) the individual is a duly qualified registered voter in Indiana; 3) the individual desires to be able to vote for the candidates listed below on the November 5, 2024 General Election Ballot; and 4) each of the undersigned respectfully requests you place the following name(s) of the legally qualified candidates for the office listed as (check one box) an independent candidate (only one (1) independent candidate allowed per petition) or independent ticket for President/Vice President or Governor/Lieutenant Governor

CANDIDATE NAME

_(Note: the candidate’s ballot name is established on the CAN-20 form)_

| COMPLETE CANDIDATE ADDRESS

(If different from residence, include mailing address. )

| OFFICE SOUGHT|
---|---|---|---
Jill Stein| 17 Trotting Horse Drive, Lexington, MA 02421| President of the United States|
Samson Komlan-LeBeau Kpadenou| 5463 Crystal Anne Dr, West Palm Beach, FL 33417| Vice President of the United States|
| | |
Office Use Only

SIGNATURE

| PRINTED NAME

First                               Last

| DATE OF BIRTH MM/DD/YYYY| RESIDENCE ADDRESS ( No P.O. Boxes )

Number              Street                         Apartment

| ****

CITY or TOWN and ZIP CODE

|
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PETITION CARRIER CERTIFICATION (Must be completed on each petition submitted for filing.)
I affirm under the penalties for perjury that I have no reason to believe that any individual whose signature appears on this page is ineligible to sign this petition or did not properly complete and sign this page.

  ,                                                     , 20 __

CARRIER’S SIGNATURE CARRIER’S PRINTED NAME CARRIER’S DATE OF BIRTH (month, day, year) _ DATE SIGNED BY CARRIER (month,_ day,

year)

 Note: Indiana state law does not require a petition carrier to be an Indiana resident or registered voter CARRIER’S FULL ADDRESS, INCLUDING ZIP CODE (number and street, city, state, and ZIP code) of Indiana to circulate or gather petition signatures for a candidate. All fields in this certification must

be completed before filing with the county closes at noon, July 1, 2024, or the petition is rejected.

COUNTY #1 VOTER REGISTRATION OFFICE CERTIFICATION| COUNTY #2 VOTER REGISTRATION OFFICE CERTIFICATION
---|---
County:| | Number of Valid Signatures:| | County:| | Number of Valid Signatures:|
I certify that, in accordance with IC 3-8-6-10(c), I have reviewed the registration records of the petitioners on this petition and certify the above number to be registered voters of this County.| I certify that, in accordance with IC 3-8-6-10(c), I have reviewed the registration records of the petitioners on this petition and certify the above number to be registered voters of this County.
Witness my/our hand and seal this

__ day of

__ , 2024, at

__ , Indiana.

| ****

COUNTY SEAL HERE

| Witness my/our hand and seal this

__ day of

__ , 2024, at

__ , Indiana.

| ****

COUNTY SEAL HERE

Signature 1| Clerk of the Circuit Court or

Member of the Board of Registration (D)

| Signature 1| Clerk of the Circuit Court or

Member of the Board of Registration (D)

Signature 2| Member of the Board of Registration (R)| Signature 2| Member of the Board of Registration (R)
PRESIDENTIAL CANDIDATE CERTIFICATION OF PRESIDENTIAL ELECTORS| As the presidential candidate nominated by the petitioners signing this petition, I certify that the following

qualified and eligible individuals are the candidates for presidential elector in Indiana pledged to support my candidacy, or if I am the candidate of a political party, the candidates of my party.

NAME| ADDRESS| NAME| ADDRESS

1

| | | ****

6

| |

2

| | | ****

7

| |

3

| | | ****

8

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4

| | | ****

9

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5

| | | ****

10

| |
NOTE: This petition may be used to nominate at least one, but no more than eleven presidential elector candidates. The presidential candidate is only required to sign one copy of this certification.| ****

11

| |
PRESIDENTIAL CANDIDATE PRINTED NAME| PRESIDENTIAL CANDIDATE SIGNATURE
AFFIDAVIT OF ASSISTANCE PROVIDED TO PETITIONER(S) WITH DISABILITIES

I affirm under the penalties for perjury that I assisted the following petitioners, due to disability, in writing the petitioner’s signature, printed name, and residence address on this petition:

Names of Petitioners Assisted by me: __

, 20

DATE ASSISTANCE PROVIDED (month, day, year)

ASSISTER’S SIGNATURE                                                ASSISTER’S PRINTED NAME                                                ASSISTER’S ADDRESS (number and street, city, state, and ZIP code)

Product Information

Specifications

• Product Name : Indiana Petition of Nomination
• Form Number : State Form 36186 (R23 / 6-23)
• Usage: Nominating independent candidates or candidates of a minor political party
• Filing Period : January 10, 2024 – Noon, July 1, 2024
• Requirements: Must be completed in petitioner’s own handwriting unless due to disability

Product Usage Instructions

Step 1: Completing the Petition
Fill in the candidate’s name, complete candidate address, office sought, and other required details as indicated on the form.

Step 2: Signing the Petition
Each signer must provide their printed name, signature, date of birth (MM/DD/YYYY), residence address (no P.O. Boxes), and city or town with ZIP code.

Step 3: Carrier Certification
The carrier must affirm that all signatures are eligible and completed correctly. Provide carrier’s signature, printed name, date of birth, date signed, and full address including ZIP code.

Step 4: Filing the Petition
Submit the completed petition to the appropriate county voter registration office within the specified filing period.

FAQ

Q: Can I file the petition after the deadline?
A: No, the petition must be filed no later than NOON, July 1, 2024, to be considered.

Q: Are there restrictions on who can circulate the petition for signatures?
A: Indiana state law does not require a petition carrier to be an Indiana resident or registered voter of Indiana to gather petition signatures for a candidate.

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