Sample Petition to Change the Municipal Code (Revised 1/30/2017)

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1 retain legal counsel to review your petition. All petitions must be approved by the Broomfield and County Clerk prior to <<< The warning and summary below must be placed on top of each page. >>> The full text of the proposed ordinance is as follows: <<< Here you will insert the full text of the proposed ordinance. It shall appear on the first page or pages of the petition section that precede the signature page. [ (3)(c) C.R.S.] >>> The following registered electors shall represent the signers of the petition in all matters affecting the same: 1. Sam Malone; 123 Main Street; Broomfield, CO Diane Chambers; 456 Main Street; Broomfield, CO <<< Each petition section shall designate by name and mailing address two persons who shall represent the proponents thereof in all matters affecting the petition and to whom all notices or information concerning the petition shall be mailed. [ (2) C.R.S.] >>> Instructions for petition signers and circulators : To sign a petition you must be a registered Broomfield voter. In the event a registered elector is physically disabled or is illiterate and wishes to sign the petition, the elector shall sign or make his or her mark in the space so provided. Any person, but not a circulator, may assist the disabled or illiterate elector in completing the remaining information required by this section. The person providing assistance shall sign his or her name and address and shall state that such assistance was given to the disabled or illiterate elector. If a signer needs assistance, a third party may provide. The third party providing assistance shall sign his or her name and address and state that (s)he rendered assistance to the elector. No person may sign for another. The circulator may not provide assistance. Print clearly using black ink. Make sure all required fields are complete. Provide the residence address you are registered to vote at, which may not be a PO box. If a small correction is made, the signer should initial the change. If a larger correction is required, the signer should completely cross out the incorrect information and proceed to use the next two blank lines. Do not leave petitions unattended. The circulator should gather all required information while the signer is present. Do not take petition sections apart or add additional pages. Do not remove any staples or binding. When finished collecting signatures, it must be properly notarized (sign the circulator affidavit in the presence of the notary) and returned to the petition representative(s). No additional persons may sign the section once notarized.

2 retain legal counsel to review your petition. All petitions must be approved by the Broomfield and County Clerk prior to

3 retain legal counsel to review your petition. All petitions must be approved by the Broomfield and County Clerk prior to

4 retain legal counsel to review your petition. All petitions must be approved by the Broomfield and County Clerk prior to AFFIDAVIT OF CIRCULATOR

5 retain legal counsel to review your petition. All petitions must be approved by the Broomfield and County Clerk prior to I,, affirm that I reside at (Circulator s printed name) (Circulator s complete residential address including street name and number, city or town, and county) and do further affirm that: I have read and understand the laws governing the circulation of petition; I was eighteen years of age or older at the time the section of the petition was circulated and signed by the listed electors; I circulated the section of the petition; Each signature thereon was affixed in my presence; Each signature thereon is the signature of the person whose name it purports to be; To the best of my knowledge and belief, each of the persons signing the petition section was, at the time of signing, a registered elector; and I have not paid or will not in the future pay and that I believe that no other person has paid or will pay, directly or indirectly, any money or other thing of value to any signer for the purpose of inducing or causing such signer to affix the signer's signature to the petition. ( Signature of Circulator) (Date of Signing) (SEAL) STATE OF COLORADO, COUNTY OF Subscribed and sworn to before me this day of, 2017 (day) (month) Signature (and Title) of Official Administering Oath My Commission Expires: