2015 Pop Petition Instructions (Page 2 of 2) in pdf

VOTER PETITION FOR REFERENDUM IN THE REPUBLICAN PRIMARY

This petition is circulated in accordance

with the Texas Election Code 172.088

This statement MUST be read to each person before signing the petition:

“I know that the purpose of this petition is to place a referendum on the 2016 general primary ballot for the

REPUBLICAN PARTY that states:

‘The State of Texas should reassert its status as an independent nation. FOR OR AGAINST’

I understand that by signing this petition I become ineligible to vote in a primary election or participate in a convention of

another party, including a party not holding a primary election, during the voting year in which this primary election is held.”

PLEASE PRINT CLEARLY AND LEGIBLY.

Name:

Are you registered to vote in Texas? Y or N

TX ID or Driver License # OR Voter Registration #

Date Signed MM DD YYYY

Birthdate MM DD YYYY

Street Address

City

Zip

County

Signature

Name:

Are you registered to vote in Texas? Y or N

TX ID or Driver License # OR Voter Registration #

Date Signed MM DD YYYY

Birthdate MM DD YYYY

Street Address

City

Zip

County

Signature

Name:

Are you registered to vote in Texas? Y or N

TX ID or Driver License # OR Voter Registration #

Date Signed MM DD YYYY

Birthdate MM DD YYYY

Street Address

City

Zip

County

Signature

Name:

Are you registered to vote in Texas? Y or N

TX ID or Driver License # OR Voter Registration #

Date Signed MM DD YYYY

Birthdate MM DD YYYY

Street Address

City

Zip

County

Signature

Name:

Are you registered to vote in Texas? Y or N

TX ID or Driver License # OR Voter Registration #

Date Signed MM DD YYYY

Birthdate MM DD YYYY

Street Address

City

Zip

County

Signature

AFFIDAVIT OF CIRCULATOR

STATE OF TEXAS COUNTY OF ___________________________ BEFORE ME, the undersigned, on this ___ / ___ / ___ (date) personally appeared

(seal)

_________________________________________________, (name of person who circulated petition,) - who

being duly sworn, deposes and says: “I called each signer’s attention to the above statements and read them

to the signer before the signer affixed their signature to the petition. I witnessed the affixing of each

signature. The correct date of signing is shown on the petition. I verified each signer’s registration status and

believe that each signature is the genuine signature of the person whose name is signed and that the

corresponding information for each signer is correct.” SWORN TO AND SUBSCRIBED BEFORE ME THIS DATE

X________________________ X_________________________ ________________________

Signature of circulator

Signature of officer administering oath

Title of office administering oath

2015 Pop Petition Instructions Page 2

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