Utah Code § 20A-7-303
"REFERENDUM PETITION To the Honorable ____, Lieutenant Governor:
We, the undersigned citizens of Utah, respectfully order that Senate (or House) Bill No. ____, entitled (title of act, and, if the petition is against less than the whole act, set forth here the part or parts on which the referendum is sought), passed by the Legislature of the state of Utah during the ____ Session, be referred to the people of Utah for their approval or rejection at a regular general election or a statewide special election;
Each signer says:
I have personally signed this referendum petition or, if I am an individual with a qualifying disability, I have signed this referendum petition by directing the signature gatherer to enter the initials "AV" as my signature;
The date next to my signature correctly reflects the date that I actually signed the referendum petition;
I have personally read the entire statement included with this referendum packet;
I am registered to vote in Utah; and
My residence and post office address are written correctly after my name.".
"It is a class A misdemeanor for an individual to sign a referendum petition with a name other than the individual's own name, or to knowingly sign the individual's name more than once for the same referendum petition, or to sign a referendum petition when the individual knows that the individual is not a registered voter.
Birth date or age information is not required, but it may be used to verify your identity with voter registration records. If you choose not to provide it, your signature may not be verified as a valid signature if you change your address before petition signatures are verified or if the information you provide does not match your voter registration records."
Verification of signature collector
State of Utah, County of ____
I, _______________, of ____, hereby state, under penalty of perjury, that:
I am at least 18 years old;
All the names that appear in this referendum packet were signed by individuals who professed to be the individuals whose names appear in it, and each of the individuals signed the individual's name on it in my presence or, in the case of an individual with a qualifying disability, I have signed this referendum petition on the individual's behalf, at the direction of the individual and in the individual's presence, by entering the initials "AV" as the individual's signature;
I certify that, for each individual whose signature is represented in this referendum packet by the initials "AV":
I obtained the individual's voluntary direction or consent to sign the referendum petition on the individual's behalf;
I do not believe, or have reason to believe, that the individual lacked the mental capacity to give direction or consent;
I do not believe, or have reason to believe, that the individual did not understand the purpose or nature of my signing the referendum petition on the individual's behalf;
I did not intentionally or knowingly deceive the individual into directing me to, or consenting for me to, sign the referendum petition on the individual's behalf; and
I did not intentionally or knowingly enter false information on the signature sheet;
I did not knowingly make a misrepresentation of fact concerning the law this petition seeks to overturn;
I believe that each individual's name, post office address, and residence is written correctly, that each signer has read the law that the referendum seeks to overturn, and that each signer is registered to vote in Utah;
The correct date of signature appears next to each individual's name; and
I have not paid or given anything of value to any individual who signed this referendum packet to encourage that individual to sign it.
________________________________________________________________________
(Name) (Residence Address) (Date).
Utah Code § 20A-7-303