Each and every sheet of every petition for either initiative or referendum containing signatures shall be verified on the back thereof in substantially the following form by the person who circulated such sheet of said petition by affidavit thereon as follows:

STATE OF OREGON    )
COUNTY OF DOUGLAS     ) ss.
CITY OF YONCALLA    )

I, _______________________, being first duly sworn, say that every person who signed this sheet of the foregoing petition, and each of them, signed his name thereto in my presence; I believe that each has stated his name, residence and street number correctly, and that each signer is a legal voter of the city of Yoncalla.

______________________
    (Signature and title of officer and his residence)