10 ILCS 5/7-59(b), 17-16.1, 18-9.1 Suggested
Revised August, 2008
SBE No. P-1F
To: _______________________________________ in the County of ____________________ and State of Illinois.
(Election Authority)
I, ___________________________________, state that I am a qualified primary elector of the _________________
Party (for use in primary only) and a resident of the __________ precinct of the (1)* township of ________________
(2)* City/Village of ____________________ or (3)* __________ ward in the City of _________________________
residing at ___________________________________ in such City, Village or Town, and State of Illinois, that It’s my
intention to be a _________________________ Party (for use in primary only) write-in candidate for the office of
___________________________________ , full term or vacancy (circle one) at the ____________________
election to be held on _________________________ (date of election).
Under penalties as provided by law pursuant to 10 ILCS 5/29-10 the undersigned certifies
that the statements set forth in this request are true and correct.
*Fill in either (1), (2) or (3)
Signature of Candidate)
Signed and sworn to (or affirmed) by _______________________________________ before me, on
(Name of Candidate)
(insert month, day, year)
(SEAL) (Notary Public’s Signature)
An original Declaration of Intent must be filed with each election authority [county
clerk(s) or board(s) of election commissioners in the territory] not later than 61
days before the election.