2013 Mississippi Code
Title 23 - ELECTIONS
Chapter 17 - AMENDMENTS TO CONSTITUTION BY VOTER INITIATIVE
§ 23-17-19 - Secretary of State to design petitions; form of petitions

The Secretary of State shall design the form each sheet of which shall contain the following:

"WARNING

EVERY PERSON WHO SIGNS THIS PETITION WITH ANY OTHER THAN HIS OR HER TRUE

NAME, KNOWINGLY SIGNS MORE THAN ONE OF THESE PETITIONS RELATING TO THE SAME

INITIATIVE MEASURE, SIGNS THIS PETITION WHEN HE OR SHE IS NOT A QUALIFIED

ELECTOR OR MAKES ANY FALSE STATEMENT ON THIS PETITION MAY BE PUNISHED BY FINE,

IMPRISONMENT, OR BOTH.

PETITION FOR INITIATIVE MEASURE

To the Honorable , Secretary of State of the State of Mississippi:

We, the undersigned citizens and qualified electors of the State of

Mississippi, respectfully direct that this petition and the proposed measure

known as Initiative Measure No. , entitled (here insert the established

ballot title of the measure), a full, true and correct copy of which is

printed or attached on the reverse side of this petition, be transmitted to

the Legislature of the State of Mississippi at its next ensuing regular

session, and we respectfully petition the Legislature to adopt the proposed

measure; and each of us for himself or herself says: I have personally signed

this petition, I am a qualified elector of the State of Mississippi in the

city (or town), county and congressional district written after my name, my

residence address is correctly stated and I have knowingly signed this

petition only once."

Each sheet shall also provide adequate space for the following information: Petitioner's signature; print name for positive identification; residence address, street and number, if any; city or town; county; precinct; and congressional district.