COMMONWEALTH OF VIRGINIA
I, , solemnly swear [or affirm] print full namethat I will continuously be present in the room in which the Official Ballots for the election to be held on , 20 , are printed from the commencement until the end of the work. I shall see that only the ballots requested to be insert number to be printedprinted by the electoral board will be printed; that all imperfect and perfect impressions other than those required to be delivered to the electoral board will be destroyed; and that all other undertakings stated on the Statement of the Printer are complied with strictly.As soon as the ballots are printed, securely wrapped and sealed, I shall take and keep them in my exclusive possession, allowing no one to examine them until I deliver them to the electoral board as provided by law.I understand that knowingly signing a false statement constitutes the crime of perjury. signature of electoral board representative Subscribed and sworn to before me this day of , 20 . signature of electoral board member or person qualified to give oathsThis Statement must be filed with the Secretary of the Electoral Boardand retained as part of the records of the Board.A copy also should be filed in the Minutes of the Board. ................
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