Mississippi Code Title 23. Elections § 23-17-19

The Secretary of State shall design the form each sheet of which shall contain the following:

“WARNING

EVERY PERSON WHO SIGNS THIS PETITION WITH ANY OTHER THAN HIS OR HER TRUE NAME, KNOWINGLY SIGNS MORE THAN ONE OF THESE PETITIONS RELATING TO THE SAME INITIATIVE MEASURE, SIGNS THIS PETITION WHEN HE OR SHE IS NOT A QUALIFIED ELECTOR OR MAKES ANY FALSE STATEMENT ON THIS PETITION MAY BE PUNISHED BY FINE, IMPRISONMENT, OR BOTH.

PETITION FOR INITIATIVE MEASURE

To the Honorable __________, Secretary of State of the State of Mississippi:

We, the undersigned citizens and qualified electors of the State of Mississippi, respectfully direct that this petition and the proposed measure known as Initiative Measure No.__________, entitled (here insert the established ballot title of the measure), a full, true and correct copy of which is printed or attached on the reverse side of this petition, be transmitted to the Legislature of the State of Mississippi at its next ensuing regular session, and we respectfully petition the Legislature to adopt the proposed measure; and each of us for himself or herself says: I have personally signed this petition, I am a qualified elector of the State of Mississippi in the city (or town), county and congressional district written after my name, my residence address is correctly stated and I have knowingly signed this petition only once.”

Each sheet shall also provide adequate space for the following information: Petitioner's signature; print name for positive identification; residence address, street and number, if any; city or town; county; precinct; and congressional district.