25 Pa. Stat. § 2871
Each candidate for election as delegate or alternate delegate to a National party convention may include, with his affidavit, the statement hereinafter set forth in this section; but his failure to include such statement shall not be a valid ground, on the part of the Secretary of the Commonwealth, for refusal to receive and file his nomination petition. Such statement, if signed, shall be signed on all the sheets of said petition, together with the date of signing and shall be in substantially the following form:
Delegate's Statement
I hereby declare to the voters of my political party in the (here insert "State of Pennsylvania," if a delegate or alternate delegate at large; otherwise, insert "District") that, if elected and in attendance as a delegate to the National convention of the party, I shall, with all fidelity, to the best of my judgment and ability, in all matters coming before the convention, support (here insert name of presidential candidate) for President of the United States and shall use all honorable means within my power to aid in securing the nomination for such candidate for President.
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(Signature of candidate for delegate or alternate delegate, and date of signing.)
On the ballots or ballot labels used at a primary, after or under the name of each candidate for delegate or alternate delegate to a National party convention, shall appear the words "committed to (here insert name of presidential candidate)" or "uncommitted" according to whether the candidate included, or failed to include, the above statement with his affidavit.
25 P.S. § 2871