Continue from Reverse Side Petition of Qualified Voters to Recall ??, Richmond, Virginia
Circulator: Must swear or affirm in the affidavid on the reverse side of htis form that s/he i s a legal resident of the United States of America, not a minor nor a felon whose voting rights have not been restored and the s/he personally witnessed each signature.

Office
use
only

Signature of Registered Voter
(Print Name in Space Below Signature)

Post Office Boxes Are Not Acceptable
Residence Address
House Number and Street Name or
Rural Route and Box Number and City/Town

Date
Signed
[Must be after
January 1 of
election year]

Optional:
Last 4 digits of
Social Security
Number
*see note front side

 

9

Sign Residence

Print City/Town Richmond, Virginia,
 

10

Sign Residence

Prints City/Town Richmond, Virginia,
 

11

Sign Residence

Print City/Town Richmond, Virginia,
 

12

Sign Residence

Print City/Town Richmond, Virginia,

Commonwealth of Virginia: -AFFIDAVIT-

I, ________________________________________________________ swear or affirm that (i) my full residential address is __________________________________________________ in the Commonwealth of Virginia, in the City of Richmond, (ii) I am a legal resident of the United States of America, (iii) I am not a minor (iv) I am not a felon whose voting rights have not been restored, and (v) I witnessedthe seignature of each person who signed this page or its reverse side. I understand that falsely signing this affidavit is a felony punishable by a maximum fine up to $2,500 and/or imprisonment up to ten years.

Place Photographically Reproducible
Notary Seal/Stamp Below

(Use your bank)


Signature of person circulating  the petition

State of Virginia, City of Richmond

The foregoing instrument was subscribed and sworn before me this
____ day of ____________________, 20___, by



Print name of person circulating the petition             


Signature of Notary or other personAuthorized to administer oaths


Notary Registration Number
Date Notary Commission Expires
If not included in seal/stamp

Privacy Notice--see front (Timists ID#____________ for lifehour credits. Notarize at bank. Mail/Deliver to ??


Circulator's Driver's
License Number, if
Applicable


Name of state that issued
the Circulator's Driver's
License


Circulator's Last 4 Digits
of Social Security
Number