Application#:C*2008Ͳ_____ForCityUseOnlyPage 1*CB=CoburgCG=CottageGrovePETITIONCR=CreswellEU=EugeneFL=FlorenceJC=JunctionCityPetitionSignatureSheetOA=OakridgeSP=SpringfieldAnnexationbyIndividualsWe,thefollowingpropertyowners/electors,consenttotheannexationofthefollowingterritorytotheCityof(InsertNameofCity):SignatureDateSignedm/d/yPrintNameResidenceAddress(street,city,zipcode)MapandTaxLotNumber(example:17Ͳ04Ͳ03Ͳ00Ͳ00100)9LandOwner9RegVoterAcres(qty)1.   2.   3.   4.   5.   Note:Withtheabovesignature(s),IamattestingthatIhavetheauthoritytoconsenttoannexationonmyownbehalforonbehalfofmyfirmoragency.(Attachevidenceofsuchauthorizationwhenapplicable.)I,______________________________________(printednameofcirculator),herebycertifythateverypersonwhosignedthissheetdidsoinmypresence.X______________________________________(signatureofcirculator)CERTIFICATIONOFPROPERTYOWNERSThetotallandownersintheproposedannexationare_____(qty).Thispetitionreflects              that_____(qty)landowners(orlegalrepresentatives)listedonthispetitionrepresentatotalLaneCountyDepartmentofAssessmentandTaxationof_____(%)ofthelandownersand_____(%)oftheacresasdeterminedbythemapand taxlotsattachedtothepetition.A&Tisnotresponsibleforsubsequentdeedactivitywhich     maynotyetbereflectedontheA&Tcomputerizedtaxroll.DateCertifiedCERTIFICATIONOFELECTORSThetotalactiveregisteredvotersintheproposedannexationare_____.Iherebycertify              thatthispetitionincludes_____validsignaturesrepresenting_____(%)ofthetotalLaneCountyClerkorDeputySignatureactiveregisteredvotersthatareregisteredintheproposedannexation.         DateCertifiedX3425 Coburg Road17-03-09-34-2900 & 30002.82