Warning: Supplying false information on this form may result in conviction of a felony with a fine of up to $125,000 and/or prison for up to 5 years. 

Instructions: Each chief petitioner is required to provide, on the same form, their name, residence address, contact phone number and signature attesting that the information on the form is true and correct. Changes to the information provided for a chief petitioner or to the circulator pay status must be reported to the Elections Division no later than the 10th day after a chief petitioner first has knowledge or should have had knowledge of the change.

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