For use of County Board of elections: date petition provided to organizing community: __/__/___
Petition for Incorporation of [
] as a Municipal Corporation in
NOTICE TO SIGNERS: You must 1) be registered to vote in the County
We, the undersigned voters of the county listed above, propose
listed above and 2) reside in the area listed above.
and express our interest in the incorporation of the area listed
above, as follows:
Sign and print your name (1) as it appears on the voter registration list,
1.
Boundaries of area proposed to be incorporated:[in accordance
OR (2) your surname of registration AND at least one full given name
with the attached]
AND the initial of any other names. Please print or type all information
other than your signature. Post Office Box addresses are not generally
2.
Name chosen for the new municipal corporation:[name
accepted as valid. By signing this petition, you agree that the area listed
cannot be the same as that used by any existing municipal
above should be incorporated as a municipality in Maryland and that,
corporation or county in the State]
to the best of your knowledge, you are registered to vote in Maryland in
the county listed above and are eligible to have your signature counted
3.
Names of individuals who will initially represent the
for this petition.
organizing community on the organizing committee:
Please Note: (1) The information you provide on this petition is public
information and may be used to change your voter registration address.
(2) Your need to provide real property information depends
on how the community will meet the numeric signature requirement. Ask
your circulator for instructions. See Maryland Code, Article 23A, §21.
Please Note: The information you provide on this petition is public information and may be used to change your voter registration address.
First Name
Middle Name
Last Name
Month
Date
Year
Print
Birth Date:
Name:
Month
Date
Year
4
Date of
1
Signature:
Signature:
Street Number
Street Name
Apt. No.
City or Town
Zip
Maryland
Residence
Address:
First Name
Middle Name
Last Name
Month
Date
Year
Print
Name:
Birth Date:
Month
Date
Year
4
Date of
2
Signature:
Signature:
Street Number
Street Name
Apt. No.
City or Town
Zip
Maryland
Residence
Address:
First Name
Middle Name
Last Name
Month
Date
Year
Print
Name:
Birth Date:
Month
Date
Year
4
Date of
3
Signature:
Signature:
Street Number
Street Name
Apt. No.
City or Town
Zip
Maryland
Residence
Address:
First Name
Middle Name
Last Name
Month
Date
Year
Print
Name:
Birth Date:
Month
Date
Year
4
Date of
4
Signature:
Signature:
Street Number
Street Name
Apt. No.
City or Town
Zip
Maryland
Residence
Address:
First Name
Middle Name
Last Name
Month
Date
Year
Print
Name:
Birth Date:
Month
Date
Year
4
Date of
5
Signature:
Signature:
Street Number
Street Name
Apt. No.
City or Town
Zip
Maryland
Residence
Address:
Circulator’s Affidavit Under penalties of perjury, I swear (or affirm) that:
(a) I was at least 18 years old when each signature was obtained; (b) the
Circulators printed name: _____________________________
information given to the left identifying me is true and correct; (c) I personally
observed each signer as he or she signed this page; and (d) to the best of
Residence Address: __________________________________
my knowledge and belief: (i) all signatures on this page are genuine; and (ii)
all signers are registered voters of Maryland. (Sign and Date when signature
City/State/Zip: _____________________________________
collection is completed)
_______________________________________________
Telephone: (_________) ______________________________
Circulator’s Signature
Date (mm/dd/yy)