Form 5-N - Affidavit Of Local Option Petitioner printable pdf download

Form No. 5-N Prescribed by Secretary of State (03-09)

AFFIDAVIT OF LOCAL OPTION PETITIONER

Revised Code Sections 4301.33, 4301.332, 4301.333 AND 4305.14

For Petition Forms 5-A, 5-C, 5-D, 5-E, 5-P, 5-Q and 5-T:

I, __________________________________________, the petitioner for a local option petition authorized by

(Insert name of Petitioner)

R.C. 4301.32, 4301.322 or 4305.14, certify that I notified all affected permit holders on the list provided by the Ohio

Division of Liquor Control of the circulation of a petition for an election for the submission of one or more of the questions

specified in R.C. 4301.35(A) through (D), R.C. 4301.351, R.C. 4301.353, R.C. 4301.354, or R.C. 4305.14(B), as

applicable. The notice was sent by certified mail within five days after I received the list from the Division. I also certify

that each part-petition contained a copy of the list of affected permit holders, if any, at the time each signer of the petition

affixed his/her signature to the petition.

_____________________________________________

(Signature of Petitioner)

_____________________________________________

(Street Name and Number)

_____________________________________________

(City, State and Zip Code)

Sworn to and signed by __________________________ in my presence in ____________________________,

County of ____________________, State of Ohio, this ______ day of ______________________, _________.

_____________________________________________

Signature and Seal of Notary Public

Notary Public, State of Ohio

My commission expires ______________________

For Petition Form 5-R (Question on Particular Use at a Specific Location):

I, ___________________________________________________________________________, the petitioner for a local

(Insert name of Petitioner, including name of business, if applicable, as it appears on petition)

option petition authorized under R.C. 4301.333, certify the proposed use of the location at ________________________

(Insert street address, including

___________________________ after the local option election will be ________________________________________.

city and zip code)

(Insert description of use)

_____________________________________________

(Signature of Petitioner)

_____________________________________________

(Street Name and Number)

_____________________________________________

(City, State and Zip Code)

Sworn to and signed by __________________________ in my presence in ____________________________,

County of ____________________, State of Ohio, this ______ day of ______________________, _________.

_____________________________________________

Signature and Seal of Notary Public

Notary Public, State of Ohio

My commission expires ______________________

WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE

Form 5-N - Affidavit Of Local Option Petitioner

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