Form 6-K - Referendum Petition (County) Page 2

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We hereby designate the following petitioners as a committee to be regarded as filing this petition.
COMMITTEE OF NOT LESS THAN THREE PETITIONERS
ADDRESS
Signatures on this petition must be from only one county and must be written in ink.
VOTING RESIDENCE
SIGNATURE
CITY, VILLAGE OR
DATE OF
ADDRESS
COUNTY
TOWNSHIP
SIGNING
STREET AND NUMBER
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