Mo. Rev. Stat. § 116.040
The following shall be substantially the form of each page of each petition for any law or amendment to the Constitution of the state of Missouri proposed by the initiative:
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 initiative 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. | ||||||
INITIATIVE PETITION | ||||||
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 following proposed law (or amendment to the constitution) shall be submitted to the voters of the state of Missouri, for their approval or rejection, at the general election to be held on the ______ day of ______, ______, 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 ______ | ||||||
If this form is followed substantially and the requirements of section 116.050 and section 116.080 are met, it shall be sufficient, disregarding clerical and merely technical errors.
§ 116.040, RSMo
Effective 6-16-99