<br />Application #: C * 2008 ‐ <br />For City Use Only <br /> <br />* CB = Coburg CG = Cottage Grove PETITION <br />CR = Creswell <br />FL = Florence <br />EU = Eugene <br />JC = Junction City Petition Signature Sheet <br />OA = Oakridge SP = Springfield Annexation by Individuals <br /> <br />We, the following property owners/electors, consent to the annexation of the following territory to the City of (Insert Name of City): <br />Signature Date Signed <br />m/d/y Print Name Residence Address <br />(street, city, zip code) <br />Map and Tax Lot Number <br />(example: 17‐04‐03‐00‐00100) <br />✓ <br />Land <br />Owner <br />✓ <br />Reg <br />Voter <br />Acres <br />(qty) <br /> <br />1. <br /> <br /> <br />2. <br /> <br /> <br />3. <br /> <br /> <br />4. <br /> <br /> <br />5. <br /> <br />Note: With the above signature(s), I am attesting that I have the authority to consent to annexation on my own behalf or on behalf of my firm or agency. (Attach evidence of such authorization when applicable.) <br /> <br />I, (printed name of circulator), hereby certify that every person who signed this sheet did so in my presence. <br />X (signature of circulator) <br /> <br /> <br />CERTIFICATION OF PROPERTY OWNERS <br />The total landowners in the proposed annexation are (qty). This petition reflects <br />that (qty) landowners (or legal representatives) listed on this petition represent a total Lane County Department of Assessment and Taxation <br />of (%) of the landowners and (%) of the acres as determined by the map and <br />tax lots attached to the petition. A&T is not responsible for subsequent deed activity which <br />may not yet be reflected on the A&T computerized tax roll. Date Certified <br />CERTIFICATION OF ELECTORS <br />The total active registered voters in the proposed annexation are . I hereby certify <br />that this petition includes valid signatures representing (%) of the total Lane County Clerk or Deputy Signature <br />active registered voters that are registered in the proposed annexation. <br /> <br /> <br /> <br />Page 1 <br />Date Certified