AFFIDAVIT OF CIRCULATOR
State of Georgia
County of __________________
Under the penalty of a violation of Code Section 16-10-71 of the Official Code of Georgia Annotated, relating to false swearing, punishable by a fine not to exceed $1,000.00 or by imprisonment of not less than one nor more than five years, or both, I do depose and say that I am an elector registered to vote in the recall election herein petitioned for and that each petitioner signed or caused to be signed the foregoing petition in my presence on the date indicated; and I believe that each signer's name and residence address are correctly stated, and that each signer is an elector of the electoral district in which such recall election will be conducted, and that each signer has read, or was read, the required statements which are also set out on each petition.
(Signature of affiant) __________________
(Residence address) __________________
(Number and street or route)
__________________
(City)
Subscribed and sworn to
before me this __________________
day of __________________, __________________.
Notary public
__________________
__________________, Georgia
My commission expires on the __________________ day of __________________, __________________.
OCGA § 21-4-8