CHIEF EXECUTIVE OFFICER’S SIGNATURE
(Signed) ..........................................................................
(chief executive officer)
..........................................................................
(Print or type name below signature)
Date: ..........................................., 20 ......... ..........................................................................
(Title of chief executive officer)
CLERK’S CERTIFICATION
I, ............................................................................, do hereby certify that I am Clerk of the .......................................
(print or type name) (local legislative body)
............................................................................................... of the .............................................................................
(county, city, town or village)
of ...................................................................................and that on the ........................ day of .................................... ,
(name)
two-thirds
20____ , such legislative body, at least of the total membership having voted in favor thereof,
a majority
(strike out one)
approved the foregoing request.
(Signed) ............................................................................
(Seal of local (clerk)
government)
..........................................................................
(Print or type name below signature)
Date: ..........................................., 20 .........
READ BEFORE SIGNING
A If the request is made by the chief executive officer and concurred in by a majority of the total membership
of the local legislative body, both the chief executive officer and the clerk of the local legislative
body must sign below. In such case use the word “majority’’ below even though the vote may have
been greater.
B. If the request is made by the local legislative body, at least two-thirds of the total membership thereof
having voted in favor of such request, only the clerk of the local legislative body must sign below.
In such case use the words “two-thirds’’ below.
IMPORTANT: READ INSTRUCTIONS ON REVERSE SIDE
HOME RULE REQUEST
(Request by a Local Government for Enactment of a Special Law)
To the Legislature:
Pursuant to Article IX of the Constitution, the .............................................................................................................of
(county, city, town or village)
Senate
...........................................................................requests the enactment of bill (no. .................................... ),
Assembly
(name)
(strike out one)
entitled “
.’’
It is hereby declared that a necessity exists for the enactment of such legislation, and that the facts
establishing such necessity are as follows: (Check appropriate box)
The local government does not have the power to enact such legislation by local law.
Other facts, as set forth in the following “Explanation” establish such necessity.
EXPLANATION
(If space below is not sufficient, use separate sheet and attach here)
Such request is made by: (Check appropriate box)
The chief executive officer of such local government, concurred in by a majority of the total membership of the
local legislative body. (See paragraph A below)
The local legislative body of such local government, at least two-thirds of the total membership thereof
having voted in favor of such request. (See paragraph B below)