PETITION FOR REFERENDUM REGARDING CREATION OF AMBULANCE DISTRICT
We, the undersigned, do hereby state that we are electors of the town qualified to vote upon a proposition to raise and expend money, within the town of Cochecton, County of Sullivan, New York; and that our places of residence are truly stated opposite our signatures hereto.
We are protesting against the resolution creating an ambulance district within the town of Cochecton and are requesting that it be submitted to the qualified electors of the district affected, for their approval or disapproval.
In witness whereof, we have signed our names on the dates indicated next to our signatures.
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DATE Signature of Petitioner
Address of Petitioner
PRINT name under Signature
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(Complete only ONE of the following)
Statement of Witness
I, , state that I am a duly qualified voter of the State of New York. I currently reside at ___________________________________________. Each of the persons that have signed this petition sheet containing ____ (fill in number) signatures, have signed their names in my presence on the dates indicated above and identified themselves to be the same person who signed the sheet. I understand that this statement will be accepted for all purposes as the equivalent of an affidavit, and if it contains a materially false statement, shall subject me to the penalties of perjury.
Date Signature of Witness
Notary Public or Commissioner of Deeds
On the dates above indicated before me personally came each of the voters whose signatures appear on this petition sheet containing ______ (fill in number) signatures, who signed same in my presence and who, being by me duly sworn, each for himself or herself, said that the foregoing statement made and subscribed by him or her, was true.
Date Signature and Official Title of Officer Administering Oath
Sheet Number __________