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Application q: C * 2008 - <br />For City Use Only <br />* CB = Coburg <br />CG = Cottage Grove <br />CR = Creswell <br />EU =Eugene <br />FL = Florence <br />JC = Junction City <br />OA = Oakridge <br />SP = Springfield <br />Attachment C <br />RECEIVED <br />CEI'VED <br />NOV L U 2016 <br />AAELA <br />SSME.NT T1 AXATION <br />PETITION <br />Petition Signature Sheet <br />Annexation by Individuals <br />r�ncnnt to the annpvatinn of the fnllnwing territory to the CitV of (insert Name of0tv): f—uc"P� <br />Signature <br />Date Signed <br />m <br />print Name <br />Residence Address <br />Map and Tax Lot Number <br />Land <br />r <br />Reg <br />Voter <br />Acres <br />I (qty) <br />11c <br />- bqq -1111 <br />.1. <br />3. <br />4. <br />5. <br />Note: Wan the aDove signalurels), i am auesemg roar 1 nave u— <br />1 (printed name of circulator), hereby certify that every person who signed this sheet did so in my presence. <br />X C (signature of circulator) <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 <br />of -W (%) of the landowners and /06 (%) 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. <br />CERTIFICATION OF ELECTORS <br />The total active registered voters in the proposed annexation are O I hereby certify <br />that this petition includes 0 _ valid signatures representing I" of the total <br />active registered voters that are registered in the proposed annexation. <br />Page 1 <br />Date Certified <br />e/W 11.fl,Ll-'. f l�L� t — <br />Lane G(6unty Clerk or Deputy Signature <br />it bull% <br />Date Certified <br />