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DO NOT COMPLETE THIS SECTION – FOR OFFICE USE ONLY
Jurisdiction
County

Legislative District

Precinct
Date Received

Surrogate Affidavit Form for the
2016 Democratic Precinct Caucus
Please place my name onto the Precinct Caucus Sign-in Sheet with the word
“Surrogate” on the signature line, and count my vote for delegate allocation for:
Name of candidate I am supporting,
or “uncommitted”
Alternate candidate, if my candidate
above is not allocated any delegates
Signature
Date
Full Name (as registered)
Please Print Clearly
Date of Birth

Gender

Home Phone

Mobile Phone

Email Address
Registration Address
Registration City

Registration Zip Code

Mailing Address
(Or “Same as Above”)
Mailing City

Mailing Zip Code
DO NOT COMPLETE THIS SECTION – FOR CAUCUS USE ONLY
Final
Preference

Delegate?

Alternate
Number?

Washington State Democrats - www.wa-democrats.org - (206) 583-0664

PLEASE TURN OVER
INCOMPLETE FORMS WILL NOT BE COUNTED

Optional
Ethnicity

LGBTQ?

Disabled?

Veteran?