Name:
Address:
County:
Birthdate:

This section is for the petition circulator only. It is required by law (Texas Election Code 141.063) to be on the same page as the signature of the petition signer. As the petition signer, you can skip this section and continue to the bottom of the form to complete your signature.

AFFIDAVIT OF CIRCULATOR | STATE OF TEXAS COUNTY OF _______________________________________

BEFORE ME, the undersigned, on this ___/___/___ (date) personally appeared __________________________________, who being duly sworn, deposes and says: “I pointed out and read to each signer, before the petition was signed, each statement pertaining to the signer that appears on the petition. I witnessed each signature. The correct date of signing is shown on the petition. I verified each signer’s registration status and believe that each signature is the genuine signature of the person whose name is signed and that the corresponding information for each signer is correct.”

SWORN TO AND SUBSCRIBED BEFORE ME ON THIS DATE

I, , hereby acknowledge that I am a registered voter in the State of Texas and the information I have provided on this petition is true and correct. It was read and pointed out to me that the purpose of this petition is to place a referendum on the 2024 general primary ballot for the REPUBLICAN PARTY that states, ‘The State of Texas should reassert its status as an independent nation. FOR OR AGAINST’ and I understand that by signing this petition, I become ineligible to vote in a primary election or participate in a convention of another party, including a party not holding a primary election, during the voting year in which this primary election is held. 

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Change fonts

• Draw Signature
  
• Type In Signature
  

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

Insert Signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signature Certificate

Document name: TEXIT Petition 2023 - Republican Party

Unique Document ID: 478518fed70a74ef74af1b0f2a5f0573a0780c04

Build. Track. Sign Contracts.

Timestamp	Audit
May 25, 2023 9:40 pm CDT	TEXIT Petition 2023 - Republican Party Uploaded by TNM Admin - [email protected] IP 71.146.42.11
May 25, 2023 9:58 pm CDT	TEXIT Petition - [email protected] added by Daniel Miller - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 25, 2023 10:00 pm CDT	TEXIT Petition - [email protected] added by Daniel Miller - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 25, 2023 10:06 pm CDT	TEXIT Petition - [email protected] added by Daniel Miller - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 25, 2023 10:10 pm CDT	TEXIT Petition - [email protected] added by Daniel Miller - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 25, 2023 10:40 pm CDT	TEXIT Petition - [email protected] added by Daniel Miller - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 25, 2023 10:45 pm CDT	TEXIT Petition - [email protected] added by Daniel Miller - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 25, 2023 10:49 pm CDT	TEXIT Petition - [email protected] added by Daniel Miller - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 25, 2023 11:42 pm CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 25, 2023 11:47 pm CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 26, 2023 12:03 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 26, 2023 12:08 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 26, 2023 12:12 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 26, 2023 12:16 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 26, 2023 12:17 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 27, 2023 10:37 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 27, 2023 10:38 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 27, 2023 10:42 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 29, 2023 12:21 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 29, 2023 12:21 am CDT	TEXIT Petition Processing - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 29, 2023 12:28 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 29, 2023 12:28 am CDT	TEXIT Petition Processing - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 29, 2023 12:30 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 29, 2023 12:46 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11
May 30, 2023 2:58 am CDT	TEXIT Petition - [email protected] added by TNM Admin - [email protected] as a CC'd Recipient Ip: 71.146.42.11

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://tnm.me/

Audit Trail Serial# b02ee7d183776dbafb299f88da75a747