​​​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. Changes to the information provided for the chief petitioner or to the circulator pay status below must be reported to the elections official no later than the 10th day after you first have knowledge or should have had knowledge of the change.

​* indicates required fields.​ ​​

​