Elec. Code, § 6567

Each candidate for delegate to the American Independent Party convention shall file with the Secretary of State, before the circulation of nomination papers of the group of candidates of which he or she is a member, an affidavit which shall be in substantially the following form:

AFFIDAVIT OF CANDIDATE FOR DELEGATE

State of California County of ______ ⎱ ⎰ ss.

I, ____, reside at No. ____ Street, in the City (or Town) of ____, in the County of ____ in the ____ Congressional District, State of California; my election precinct is ____ and I reside and am a voter therein, my post office address is ____, County of ____.

I desire to be a candidate, at the presidential primary to be held on the ____ day of ____, 20__, for delegate to the next national convention of the American Independent Party, and if elected as delegate I will qualify.

I personally prefer ____ as nominee of the American Independent Party for President of the United States, and hereby declare to the voters of my party in the State of California that if elected as delegate to their national party convention, I shall to the best of my judgment and ability, support ____ as nominee of the American Independent Party for president of the United States. (This statement of preference shall be omitted where the candidate for delegate is part of a group not expressing a preference for a particular candidate.)

I express no preference for a particular candidate. The chairman of my group is ____. (This statement shall be omitted where the candidate for delegate is part of a group expressing a preference for a particular candidate.)

I declare under penalty of perjury that the foregoing is true and correct.

(Signed) _________________________________________________________