____________________________________ ________________________
INITIATIVE PETITION
CERTIFICATION FORM
County:_________________ Initiative Serial Number:
_______________
Initiative Title:_________________________________________________________________
Batch
Certification
Congressional Valid Verified
District Signatures
I hereby certify thes e valid verified s ignatures are not contained in any prior certification.
Signature of Supervis or of
Elections Date
Please provide a copy of the petition along with this
form.
DS-DE 144 (Revised 6/2015)