Form SBE-506/521 "Petition of Qualified Voters" - Virginia

What Is Form SBE-506/521?

This is a legal form that was released by the Virginia Department of Elections - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2013;
  • The latest edition provided by the Virginia Department of Elections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SBE-506/521 by clicking the link below or browse more documents and templates provided by the Virginia Department of Elections.

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Download Form SBE-506/521 "Petition of Qualified Voters" - Virginia

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SPECIAL NOTE REGARDING
PETITION OF QUALIFIED VOTERS FORM
The Petition of Qualified Voter form (SBE-506/521) is a two
page document (front and back) printed on one piece of 8
½" x 14" paper. When you print this form, it should be
printed front and back on one 8 ½" x 14" sheet of paper. If
you are unable to print a double-sided print job, you may
print two separate pages. However, you must then
reproduce/copy the two pages into one page. The front of
the petition contains line numbers 1 through 10; the back of
the form contains line numbers 11 through 21 followed by
the AFFIDAVIT. If you are unable to print or reproduce this
form on 8 ½" x 14" printed back and front, then call our
office at 800-552-9745 or 804-864-8901 and we will be glad
to send you a form.
SPECIAL NOTE REGARDING
PETITION OF QUALIFIED VOTERS FORM
The Petition of Qualified Voter form (SBE-506/521) is a two
page document (front and back) printed on one piece of 8
½" x 14" paper. When you print this form, it should be
printed front and back on one 8 ½" x 14" sheet of paper. If
you are unable to print a double-sided print job, you may
print two separate pages. However, you must then
reproduce/copy the two pages into one page. The front of
the petition contains line numbers 1 through 10; the back of
the form contains line numbers 11 through 21 followed by
the AFFIDAVIT. If you are unable to print or reproduce this
form on 8 ½" x 14" printed back and front, then call our
office at 800-552-9745 or 804-864-8901 and we will be glad
to send you a form.
COMMONWEALTH OF VIRGINIA
PETITION OF QUALIFIED
VOTERS
,
[
]
ENTER ABOVE
NAME OF CANDIDATE
SHOULD BE AS IT IS TO APPEAR ON BALLOT
[Must be filed with Declaration of Candidacy]
When an election district includes more than one
county or city, it is suggested that you use a
,
ENTER ABOVE
RESIDENCE ADDRESS OF CANDIDATE
separate petition form for qualified voters in each
county or city to facilitate the processing of the
filing.
For a statewide office
,
/
,
+ 4
ENTER ABOVE
CITY
TOWN
ENTER ABOVE
ZIP
It is suggested that you file petitions in county/city
to facilitate the processing of the filing. If you track
the number of signatures by congressional district
,
,
,
ENTER ABOVE
OFFICE SOUGHT
ENTER ABOVE
DISTRICT
IF APPLICABLE
enter district no.:
[optional].
We, the qualified voters of the district in which the above candidate seeks nomination or election and of
All signatures required by law need not be on
signed hereunder or on the reverse
the same page of the petition. Numerous
,
,
pages may be circulated. The circulator of
COUNTY OR CITY OR
FOR TOWN COUNCIL
NAME OF TOWN
side of this page, do hereby petition the above named individual to become a candidate for the office stated
each page must be a person who is her\himself
above in the [check only one]
a legal resident of the United States of America




and who is not a minor nor a felon whose
General Election
Special Election
D emocratic Primary
Republican Primary
voting rights have not been restored. The
to be held on the ___________ day of __________________________, 20 ____, and we do further petition
circulator also must swear or affirm in the
that his/her name be printed upon the official ballots to be used at the election.
affidavit that s/he personally witnessed the
signature of each voter.
:
/
,
CIRCULATOR
MUST SWEAR OR AFFIRM IN THE AFFIDAVIT ON THE REVERSE SIDE OF THIS FORM THAT S
HE IS A LEGAL RESIDENT OF THE UNITED STATES OF AMERICA
NOT A
/
.
MINOR NOR A FELON WHOSE VOTING RIGHTS HAVE NOT BEEN RESTORED AND THAT S
HE PERSONALLY WITNESSED EACH SIGNATURE
:
.
SIGNER
YOUR SIGNATURE ON THIS PETITION MUST BE YOUR OWN AND DOES NOT SIGNIFY AN INTENT TO VOTE FOR THE CANDIDATE
YOU MAY SIGN PETITIONS FOR MORE
.
THAN ONE CANDIDATE
O
DATE
FFICE
USE
SIGNED
POST OFFICE BOXES ARE NOT
*
SEE NOTE BELOW
ONLY
[Must be
ACCEPTABLE
after
LAST 4 DIGITS OF
RESIDENCE ADDRESS
January 1
SOCIAL SECURITY
SIGNATURE OF REGISTERED VOTER
House Number and Street Name or
of election
NUMBER
[
]
Rural Route and Box Number and City/Town
PRINT NAME IN SPACE BELOW SIGNATURE
year]
[
]
OPTIONAL
SIGN
RESIDENCE
1.
C
/T
ITY
OWN
PRINT
SIGN
RESIDENCE
2.
C
/T
PRINT
ITY
OWN
SIGN
RESIDENCE
3.
C
/T
ITY
OWN
PRINT
SIGN
RESIDENCE
4.
C
/T
PRINT
ITY
OWN
SIGN
RESIDENCE
5.
C
/T
PRINT
ITY
OWN
SIGN
RESIDENCE
6.
C
/T
PRINT
ITY
OWN
SIGN
RESIDENCE
7.
C
/T
PRINT
ITY
OWN
SIGN
RESIDENCE
8.
C
/T
PRINT
ITY
OWN
SIGN
RESIDENCE
9.
C
/T
ITY
OWN
PRINT
SIGN
RESIDENCE
10.
C
/T
PRINT
ITY
OWN
CONTINUE ADDITIONAL SIGNATURES AND COMPLETE AFFIDAVIT ON REVERSE SIDE
*
:
Privacy notice
The Code of Virginia, §§ 24.2-506 and 24.2-521, authorizes requesting the last four digits of your social security number to facilitate
checking this petition with the official voter registration record. You are not required to provide this information and may sign the petition without doing
so. The State Board of Elections or the General Registrar, when copying this document for public inspection, must cover the column containing any
social security number or part thereof.
SBE-506/521 REV 1.2013
CANDIDATE NAME
OFFICE SOUGHT
: ______________________
: ___________________________
CONTINUED FROM REVERSE SIDE
:
/
,
CIRCULATOR
MUST SWEAR OR AFFIRM IN THE AFFIDAVIT BELOW THAT S
HE IS A LEGAL RESIDENT OF THE UNITED STATES OF AMERICA
NOT A MINOR NOR A
FELON
WHOSE
/
.
VOTING RIGHTS HAVE NOT BEEN RESTORED AND THAT S
HE PERSONALLY WITNESSED EACH SIGNATURE
:
.
SIGNER
YOUR SIGNATURE ON THIS PETITION MUST BE YOUR OWN AND DOES NOT SIGNIFY AN INTENT TO VOTE FOR THE CANDIDATE
YOU MAY SIGN PETITIONS FOR MORE
.
THAN ONE CANDIDATE
O
DATE
FFICE
USE
SIGNED
POST OFFICE BOXES ARE NOT
*
SEE NOTE BELOW
ONLY
[Must be
ACCEPTABLE
after
LAST 4 DIGITS OF
RESIDENCE ADDRESS
January 1
SOCIAL SECURITY
SIGNATURE OF REGISTERED VOTER
House Number and Street Name or
of election
NUMBER
[
]
Rural Route and Box Number and City/Town
PRINT NAME IN SPACE BELOW SIGNATURE
year]
[
]
OPTIONAL
SIGN
RESIDENCE
11.
C
/T
PRINT
ITY
OWN
SIGN
RESIDENCE
12.
C
/T
ITY
OWN
PRINT
SIGN
RESIDENCE
13.
PRINT
C
/T
ITY
OWN
SIGN
RESIDENCE
14.
C
/T
PRINT
ITY
OWN
SIGN
RESIDENCE
15.
C
/T
PRINT
ITY
OWN
SIGN
RESIDENCE
16.
C
/T
ITY
OWN
PRINT
SIGN
RESIDENCE
17.
C
/T
PRINT
ITY
OWN
SIGN
RESIDENCE
18.
C
/T
ITY
OWN
PRINT
SIGN
RESIDENCE
19.
C
/T
PRINT
ITY
OWN
SIGN
RESIDENCE
20.
C
/T
PRINT
ITY
OWN
SIGN
RESIDENCE
21.
C
/T
PRINT
ITY
OWN
- AFFIDAVIT
Commonwealth of Virginia
-
I, ___________________________________________________________________, swear or affirm that (i) my full residential
CIRCULATOR
S DRIVER
S
,
address is ____________________________________________________________________ in the State/Commonwealth of
LICENSE NUMBER
IF
__________________________; in the County/City/Town of_________________________________; (ii) I am a legal resident of
APPLICABLE
the United States of America; (iii) I am not a minor; (iv) I am not a felon whose voting rights have not been restored; and (v) I
witnessed the signature of each person who signed this page or its reverse side. I understand that falsely signing this affidavit is a
NAME OF STATE THAT ISSUED
felony punishable by a maximum fine up to $2,500 and/or imprisonment up to ten years.
THE CIRCULATOR
S DRIVER
S
LICENSE
______________________________________________________
PLACE PHOTOGRAPHICALLY REPRODUCIBLE
SIGNATURE OF PERSON CIRCULATING THE PETITION
4
CIRCULATOR
S LAST
DIGITS
/
NOTARY SEAL
STAMP BELOW
DATE
OF SOCIAL SECURITY
State of ______________________ County/City of ________________________
NUMBER
The foregoing instrument was subscribed and sworn before me this
________ day of ____________________________ , 20 ____ , by
_______________________________________________________ .
PRINT NAME OF PERSON CIRCULATING THE PETITION
___________________________________________________
______________________ ________________________
**
**
SIGNATURE OF NOTARY OR OTHER PERSON AUTHORIZED TO ADMINISTER OATHS
NOTARY REGISTRATION NUMBER
DATE NOTARY COMMISSION EXPIRES
*
Privacy notice: The Code of Virginia, §§ 24.2-506 and 24.2-521, authorizes requesting the last four digits of your social security number to facilitate
checking this petition with the official voter registration record. You are not required to provide this information and may sign the petition without
doing so. The State Board of Elections or the General Registrar, when copying this document for public inspection, must cover the column containing
any social security number or part thereof.
BE-506/521 REV 1.2013
** If not included in seal/stamp.
S
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