PETITION FOR THE RECALL OF

______________________________________________________________

FOR THE OFFICE OF

______________________________________________________________

By the: Committee to Recall _________________________ For the Office of _________________________

The recall is for ______________________________, ___________________________________

(Name of Elected Official)

(Office of Elected Official)

We have three sponsors listed below with signatures

We represent the Committee to Recall ________________________________________________;
for the Office of __________________________________________________________________
We, the undersigned, certify that we are sponsors of the Committee to Recall _________________,
and that we are registered to vote in ______________________________. We support the recall
and accept responsibility associated with the serving on the Recall Committee.
The recall should be held at the ________________________ election.
(general, regular municipal or special)

If applicable, the estimated cost of a special election is __________________________________.

STATEMENT OF THE RECALL COMMITTEE OR DECLARATION THAT NO STATEMENT WAS

PROVIDED (Optional- not to exceed 200 words)

RESPONSEOF
STATEMENT
OF COMMITTEE
THE ELECTED
OFFICIAL
TO BE RECALLED
OR DECLARATION
THE RECALL
OR
DECLARATION
THAT NO STATEMENT
WAS
STATEMENT
to exceed 200 words)
THAT NO RESPONSE
WAS PROVIDED (Optional - not to exceed 200 words):
(Optional- notSTATEMENT
PROVIDED

The Recall Committee is listed below:

1. _______________________________________________________________________________________________
Signature

Print Name

_______________________________________________________________________________________________
Residence Address (Number and Street)

Municipality

Zip Code

2. _______________________________________________________________________________________________
Signature

Print Name

_______________________________________________________________________________________________
Residence Address (Number and Street)

Municipality

Zip Code

3. _______________________________________________________________________________________________
Signature

Print Name

_______________________________________________________________________________________________
Residence Address (Number and Street)

Municipality

Zip Code

THE FORMAT OF THIS PETITION HAS BEEN APPROVED BY THE APPROPRIATE RECALL
ELECTION OFFICIAL.
(Signature) ____________________________________________
(Title) ____________________________________________
(Date) ____________________________________________

Page 1

Petition to Recall ___________________________ from the Office of ___________________________

Signature and residence address of registered voter:
1.

Page _____ of _____

_______________________________________________________________________________________________
Signature

Print Name

_______________________________________________________________________________________________
Residence Address (Number and Street)

Municipality

I had the opportunity to review the information on the first page of this petition.

Zip Code

Date: ____________________

2. _______________________________________________________________________________________________
Signature

Print Name

_______________________________________________________________________________________________
Residence Address (Number and Street)

Municipality

I had the opportunity to review the information on the first page of this petition.

Zip Code

Date: ____________________

3. _______________________________________________________________________________________________
Signature

Print Name

_______________________________________________________________________________________________
Residence Address (Number and Street)

Municipality

I had the opportunity to review the information on the first page of this petition.

Zip Code

Date: ____________________

4. _______________________________________________________________________________________________
Signature

Print Name

_______________________________________________________________________________________________
Residence Address (Number and Street)

Municipality

I had the opportunity to review the information on the first page of this petition.

Zip Code

Date: ____________________

5. _______________________________________________________________________________________________
Signature

Print Name

_______________________________________________________________________________________________
Residence Address (Number and Street)

Municipality

I had the opportunity to review the information on the first page of this petition.

State of New Jersey

County of

Zip Code

Date: ____________________

:
: ss.
:

I, ______________________________________, being duly sworn, upon my oath say that my address is

_____________________________________, that I assumed responsibility for circulating this Petition
and that I witnessed the signing of this page by each person whose signature appears thereon; that to the
best of my information and belief, the signers are legal residents of _____________, New Jersey and that
(County)

this signature page was circulated in absolute good faith for the purpose of causing the recall of
________________________ for the office of _______________________, named on the first page of this
Petition. The dates between which signatures on this page were collected are _____/_____/_____ and
_____/_____/_____/.
Sworn and subscribed to before me in
____________________________________ N.J.,

on

___________________________________________

(List County where Affidavit was signed and notarized)

(Signature of Circulator/Witness)

this ___________________________ day of

___________________________________________

(Day)

(Residence Address)

______________, 20_____
(Month)

___________________________________________

(Year)

(Municipality)
_____________________________________________________

(Notary Signature)
_____________________________________________________

(My Commission Expires)

Page 2

(Zip Code)