§ 321.495

Title XXI PUBLIC SAFETY AND MORALS Chapter 321 • Effective - 28 Aug 1978 321.495. Form of petition. — 1. A petition for a referendum shall be in substantially the following form: WARNING It is a felony for anyone to sign any initiative or referendum petition with any name other than his own, or to knowingly sign his name more than once for the measure, or to sign such petition when he is not a legal voter. INITIATIVE PETITION To the board of directors of the ______ Fire Protection District: We the undersigned, citizens and voters of the state of Missouri and the ______ Fire Protection District, respectfully order that (describe the measure) shall be referred to the people of the district for their approval or rejection, at the regular (special) election to be held on the ______ day of ______, 20______, and each for himself says: I have personally signed this petition; I am a duly qualified elector of the state and district; my residence and post-office address are correctly written after my name. Name ______ Residence ______ Post Office ______ (if in a city, street and number) (Here follow numbered lines for signatures.) 2.

esidence and post-office address are correctly written after my name. Name ______ Residence ______ Post Office ______ (if in a city, street and number) (Here follow numbered lines for signatures.) 2. Every sheet for petitioners' signatures shall be attached to a full and correct copy of the title and text of the measure proposed by the initiative petition. Referendum petitions shall be attached to a full and correct copy of the measure on which the referendum is demanded. 3. Each sheet of every petition containing signatures shall be verified in substantially the following form by the person who circulated the sheet, by his affidavit thereon: State of Missouri County of ______ I, ______, being first duly sworn, say that each person whose name appears on this sheet signed his name thereto in my presence; I believe that each has stated his name, post-office address and residence correctly, and that each signer is a voter of the state of Missouri and ______ Fire Protection District. (signature and post-office address of affiant) Subscribed and sworn to before me this ______ day of ______, 20______ (signature and title of officer before whom oath is made and his post-office address)

gnature and post-office address of affiant) Subscribed and sworn to before me this ______ day of ______, 20______ (signature and title of officer before whom oath is made and his post-office address) ­­-------- (L. 1969 H.B. 322, A.L. 1978 H.B. 971)