(a) The form of the recall petition shall be substantially as follows:

RECALL PETITION

__________________________ (Official application no.)

__________________________ (County or city)

To __________________________________ Name of election superintendent)

_________________________________ (Address)

_________________________________ (City, state, ZIP Code)

We, the electors registered to vote in the recall election herein petitioned, demand the recall of ______________________ (Name and office) on the grounds that said official has, while holding public office, conducted himself or herself in a manner which relates to and adversely affects the administration of his or her office and adversely affects the rights and interest of the public and that said official ______________ (State the appropriate ground or grounds for recall as set forth in subparagraph (B) of paragraph (7) of Code Section 21-4-3 and a brief statement, not to exceed five lines, of the fact or facts upon which such ground or grounds are based.).

Date of Residence County of Name Signing Address Residence ___________________________________________________ (Signature) (Number and street or route)

_________________________ ___________________ (Printed name of elector) (City)

(Ten lines for signatures and printed names)

(b) The following statements shall be written or printed on each petition and each signer must read, or be read, the following statements:

"(1) Any person who gives or receives money or any other thing of value for signing a recall petition or for signing an affidavit of signature withdrawal shall be guilty of a misdemeanor;

(2) If (insert appropriate number) electors sign this petition, there will be an election at which a majority of the electors voting therein will determine whether the above-named official will be removed from office."

(c) Each recall petition shall contain a statement specifically designating the name and office of the official sought to be recalled, a statement that the named official has, while holding public office, conducted himself or herself in a manner which relates to and adversely affects the administration of his or her office and adversely affects the rights and interests of the public, a statement containing the appropriate ground or grounds for recall as set forth in subparagraph (B) of paragraph (7) of Code Section 21-4-3, and a brief statement of the fact or facts upon which such ground or grounds are based. Such statements shall be written or printed on each petition and each signer must read, or be read, such statements.