WARNING TO PETITION SIGNERS-VIOLATION OF ANY OF THE FOLLOWING PROVISIONS OF LAW MAY RESULT IN THE FILING OF CRIMINAL CHARGES: Any person who signs any name other than his or her own to any petition or who is not qualified to sign the petition shall be guilty of a Class I misdemeanor. Any person who falsely swears to a circulator's affidavit on a petition, who accepts money or other things of value for signing a petition, or who offers money or other things of value in exchange for a signature upon any petition shall be guilty of a Class IV felony.
STATE OF NEBRASKA ) | |
) | ss. |
COUNTY OF ....... ) |
..........................., (name of circulator) being first duly sworn, deposes and says that he or she is the circulator of this petition containing .......... signatures, that he or she is at least eighteen years of age, that each person whose name appears on the petition personally signed the petition in the presence of the affiant, that the date to the left of each signature is the correct date on which the signature was affixed to the petition and that the date was personally affixed by the person signing such petition, that the affiant believes that each signer has written his or her name, street and number or voting precinct, and city, village, or post office address correctly, that the affiant believes that each signer was qualified to sign the petition, and that the affiant stated to each signer the object of the petition as printed on the petition before he or she affixed his or her signature to the petition.
Circulator ...........................
Address ..............................
Subscribed and sworn to before me, a notary public, this ...... day of ......... 20.... at ..............., Nebraska.
Notary Public ...........................
Neb. Rev. Stat. §§ 32-628