101 Pa. Code § 19.512
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF DAUPHIN
____________ , being duly sworn according to law, says:
That he resides at ____________ , ____________ County, Pennsylvania.
That he is a Sergeant-at-Arms of the House of Representatives, Commonwealth of Pennsylvania, specially deputized.
That he served on the Board of Elections of Allegheny County, on the ___ day of ___ , 1984, at ___ o'clock, at its office in Pittsburgh, a writ for a special election for the office of Representative in the General Assembly for the Eighth Legislative District of the County of Allegheny, by command of the Honorable K. Leroy Irvis, Speaker of the House of Representatives of the Commonwealth of Pennsylvania.
____________
Sergeant-at-Arms
Sworn and subscribed to
before me this ___
day of ___ , 1984
____________
101 Pa. Code § 19.512