COMMONWEALTH OF PENNSYLVANIA:
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COUNTY OF MIFFLIN:
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ss:
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PERSONALLY APPEARED BEFORE ME, ______________________________,
(Mayor of the Borough of Burnham) or (Judge of Mifflin County) or
(a District Justice in and for any magisterial district in Mifflin
County), ______________________________, elected Councilman in and
for the Borough of Burnham, Mifflin County, Pennsylvania, who being
duly (sworn or affirmed) according to law, doth depose and say: that
I will support, obey and defend the Constitution of the United States,
and the Constitution of this Commonwealth and that I will discharge
the duties of my office with fidelity: that I have not paid or contributed,
or promised to pay or contribute, either directly or indirectly, any
money or other valuable thing, to procure my nomination or election
except for necessary and proper expense expressly authorized by law;
that I have not knowingly violated any election law of this Commonwealth,
or procured it to be done by others in my behalf; that I will not
knowingly receive, directly or indirectly, any money or other valuable
thing for the performance or nonperformance of any act or duty pertaining
to my office, other than the compensation allowed by law.
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Sworn to (or affirmed) before me this _____ day of ____________________,
A.D., 19_____
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