PROXY Know all persons by these present, that I, the undersigned, a member of the Jackson County Democratic Committee,

duly elected from the __________ Ward/Sub-district, __________________ Township, do hereby constitute and appoint the bearer, __________________________ (bearers full name) to be my lawful attorney substitute and proxy at the ________________________meeting to be held on the __________day of _____________, 20___, at (location) _____________________, Missouri at _________ oclock, and at any adjourned or postponed meeting thereof, and hereby grant my proxy full power and authority to act in my stead, and with the same effect, as I might or could do were I present in such meeting in person, and hereby ratify and confirm all that my said attorney or proxy may lawfully do at such a meeting in my place or stead.

__________________________________ Committee Member Signature __________________________________ Ward/Sub-district/Township

This document must be notarized unless you have signed the signature file held by the Secretary. A maximum of two (2) proxies may be tendered at any one (1) meeting by any committee member.

1/18/13