PETITION FOR NOMINATION

(To Form a New Political Party)

We, the undersigned, qualified voters of the 92th Representative District in the State of Illinois do declare that it is our intention to form a new political party in the political division aforesaid, to be known and designated as the Libertarian Party, and do hereby petition that the following named person shall be a candidate for the office of State Representative of the division hereinafter specified, to be voted on at the General Election to be held on November 3, 2020 (date of election).

NAME OFFICE ADDRESS CITY STATE ZIPCODE
Chad Grimm Illinois House of Representatives, 92th District of Illinois
125 E. Glen Ave., Unit #116B, Peoria, IL 61614
If required pursuant to 10 ILCS 5/7-10.2, 8-8.1 or 10-5.1, complete the following (this information will appear on the ballot)
(List all names during last 3 years) (List date of each name change)
FORMERLY KNOWN AS (None) UNTIL NAME CHANGED ON (N/A)

Voter's Info:
Full Legal Name: County:
Address: Unit: Zip:

Email:


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