RSA 655:21: Form.

Primary petitions shall be made in the following form:

State of New Hampshire

County of ____________________ ss.

City (Town) of ____________________

I do hereby join in a petition for the printing on the primary ballot of the name of __________ whose domicile is in the city (town) of __________ (ward, street, and number, if in a city), in the county of __________ , for the office of __________ to be voted for on Tuesday, the __________ day of September, _____ (year), and certify that I am qualified to vote for a candidate for said office, that I am a registered member of the __________ party, and am not at this time a signer of any other similar petition for any other candidate for the above office; that my domicile is in the city (town) of __________ (ward, street, and number, if in a city), in the county of __________ . I certify that to my knowledge the above-named candidate is not a candidate for incompatible offices as defined in RSA 655:10, and that he or she is not a federal employee which makes him or her ineligible to file as a candidate for this office. I further certify that I believe the above-named person is especially qualified to fill said office.

I hereby swear, under the penalties for voting fraud set forth below, that the information above is true and correct to the best of my knowledge and belief.

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| Print Voter's name

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| Voter's Signature

In accordance with RSA 659:34, the penalty for knowingly or purposefully providing false information when registering to vote or voting is a class A misdemeanor with a maximum sentence of imprisonment not to exceed one year and a fine not to exceed $2,000. Fraudulently registering to vote or voting is subject to a civil penalty not to exceed $5,000.