Missouri Statutes § 116.030 Referendum petition, form - clerical and technical errors to be disregarded, penalties for false signature

County ______

Page No. ______

It is a class A misdemeanor punishable, notwithstanding the provisions of section 560.021 , RSMo, to the contrary, for a term of imprisonment not to exceed one year in the county jail or a fine not to exceed ten thousand dollars or both, for anyone to sign any referendum petition with any name other than his or her own, or knowingly to sign his or her name more than once for the same measure for the same election, or to sign a petition when such person knows he or she is not a registered voter.

PETITION FOR REFERENDUM

To the Honorable ______, Secretary of State for the state of Missouri:

We, the undersigned, registered voters of the state of Missouri and ______ County (or City of St. Louis), respectfully order that the Senate (or House) Bill No. ______ entitled (title of law), passed by the ______ general assembly of the state of Missouri, at the ______ regular (or special) session of the ______ general assembly, shall be referred to the voters of the state of Missouri, for their approval or rejection, at the general election to be held on the ______ day of ______, ______, unless the general assembly shall designate another date, and each for himself or herself says: I have personally signed this petition; I am a registered voter of the state of Missouri and ______ County (or City of St. Louis); my registered voting address and the name of the city, town or village in which I live are correctly written after my name.

(Official Ballot title) ______

CIRCULATOR'S AFFIDAVIT

State Of Missouri,

County Of ______

I, ______, being first duly sworn, say (print or type names of signers)

NAME

DATE SIGNED

REGISTERED VOTING ADDRESS

ZIP CODE

CONGR. DIST.

NAME

(Signature)

(Street) (City,

(Printed or

Town or Village)

Typed)

(Here follow numbered lines for signers)

signed this page of the foregoing petition, and each of them signed his or her name thereto in my presence; I believe that each has stated his or her name, registered voting address and city, town or village correctly, and that each signer is a registered voter of the state of Missouri and ______ County. FURTHERMORE, I HEREBY SWEAR OR AFFIRM UNDER PENALTY OF PERJURY THAT ALL STATEMENTS MADE BY ME ARE TRUE AND CORRECT AND THAT I HAVE NEVER BEEN CONVICTED OF, FOUND GUILTY OF, OR PLED GUILTY TO ANY OFFENSE INVOLVING FORGERY.

I am at least 18 years of age. I do ______ do not ______ (check one) expect to be paid for circulating this petition. If paid, list the payer ______

__________________

Signature of Affiant

(Person obtaining signatures)

__________________

(Printed Name of Affiant)

__________________

Address of Affiant

Subscribed and sworn to before me this ______ day of ______, A.D. ______

__________________

Signature of Notary

Address of Notary

Notary Public (Seal)

My commission expires ______