An Act
ENROLLED HOUSE
BILL NO. 1041 By: Randleman of the House
and
Stanley of the Senate
An Act relating to schools; amending 70 O.S. 2021,
Section 11-103.6, as amended by Section 51, Chapter
228, O.S.L. 2022 (70 O.S. Supp. 2022, Section 11-
103.6), which relates to subject matter standards;
authorizing school district to issue alternate
diploma to students in the Okla homa Alternate
Assessment Program; prescribing criteria for
alternate diploma; directing individual ized education
program team to determine subsequent courses and
services; prohibiting preclusion from completing
standard diploma requirements; authorizing alternate
diploma to count in calculating and reporting
graduation rate; requiring curriculum units for award
of alternate diploma; allowing substitution of core
curriculum courses; updating statutory language ;
providing an effective date ; and declaring an
emergency.
SUBJECT: Schools
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 70 O.S. 2021, Section 11 -103.6, as
amended by Section 51, Chapter 228, O.S.L. 2022 (70 O.S. Supp. 2022,
Section 11-103.6), is amended to read as follows:
Section 11-103.6 A. 1. The State Board of Education shall
adopt subject matter standards for instruction of students in the
public schools of this state that are necessary to ensure there is
attainment of desired levels of competenci es in a variety of areas ENR. H. B. NO. 1041 Page 2
to include language, mathematics, science, social studies,
communication, and health and physical education.
2. School districts shall develop and implement curriculum,
courses and instruction in order to ensure that students meet the
skills and competencies as set forth in this section and in the
subject matter standards adopted by the State Board of Education.
3. All students shall gain literacy at the elementary and
secondary levels. Students shall develop skills in reading,
writing, speaking, computing and critical thinking. For purposes of
this section, critical thinking means a manner of analytical
thinking which is logical and uses linear factual analysis to reach
a conclusion. They shall learn about cultures and environm ents -
their own and those of others with whom they share the earth. All
students shall receive the instruction needed to lead healthy and
physically active lifestyles. Students, therefore, shall study
social studies, literature, languages, the arts, hea lth, mathematics
and science. Such curricula shall provide for the teaching of a
hands-on career exploration program in cooperation with technology
center schools.
4. The subject matter standards shall be designed to teach the
competencies for which stud ents shall be tested as provided in
Section 1210.508 of this title, and shall be des igned to prepare all
students for active citizenship, employment and/or successful
completion of postsecondary education without the need for remedial
coursework at the pos tsecondary level.
5. The subject matter standards shall be designed with rigor as
defined in paragraph 3 of subsection G of this section.
6. The subject matter standards for English Language Arts shall
give Classic Literature and nonfiction literature eq ual
consideration to other literature. In addition, emphasis shall be
given to the study of complete works of literature.
7. At a minimum, the subject matter standards for mathematics
shall require mastery of the standard algorithms in mathematics,
which is the most logical, efficient way of solving a problem that
consistently works, an d for students to attain fluency in Euclidian
geometry.
8. The subject matter standards for history, social studies and
United States Government shall include study of imp ortant historical ENR. H. B. NO. 1041 Page 3
documents, including the United States Constitution, Declaration o f
Independence, Emancipation Proclamation, Federalist Papers and other
documents with significant history and heritage of the United
States, and the content of the United S tates naturalization test,
with an emphasis on the specific content of the test and the ideas
and concepts it references. Beginning with the 2022 -2023 school
year, the United States naturalization test shall be administered in
accordance with subsection F of this section.
9. The subject matter standards for United States Government
shall include an emphasis on civics, the structure and relationship
between the national, state, county and local governments and
simulations of the democratic process. For th e purposes of this
section, "civics" means the study of the rights and duties of
Oklahoma and United States citizens and of how those governments
work.
10. The subject matter standards for health and physical
education shall include but not be limited to the domains of
physical, emotional, social and intellectual health. Health
literacy shall include the ability to obtain, process and understand
basic health information and services needed to make appropriate
health decisions. Health shall also include t he importance of
proper nutrition and exercise, mental health and wellness, substanc e
abuse, coping skills for understanding and managing trauma,
establishing and maintaining positive relationships and responsible
decision making. Physical literacy shall include the ability to
move with competence and confidence in a wide variety of phys ical
activities in multiple environments that benefit the healthy
development of the whole person.
B. Subject to the provisions of subsection C of this section,
in order to graduate from a public high school accredited by the
State Board of Education with a standard diploma, students shall
complete the following college preparatory/work ready curriculum
units or sets of competencies at the secondary level:
1. Four units or sets of competencies of English to include
Grammar, Composition, Literature, or any English course approved for
college admission requirements;
2. Three units or sets of competencies of mathematics, limited
to Algebra I, Algebra II, Geometry, Trigonometr y, Math Analysis,
Calculus, Advanced Placement Statistics, or any mathematics course ENR. H. B. NO. 1041 Page 4
with content and/or rigor above Algebra I and approved for college
admission requirements;
3. Three units or sets of competencies of laboratory science
approved for college admission requirements including one unit or
set of competencies of life science meeting the standards for
Biology I; one unit or set of competencies of physical science,
meeting the standards for Physical Science, Chemistry or Physics;
and one unit or set of competencies from the domains of physical
science, life science or earth and space science such that the
content and rigor is above Biology I or Physical Science;
4. Three units or sets of competencies of history and
citizenship skills, including o ne unit of American History, one-half
unit of Oklahoma History, one -half unit of United States Government
and one unit from the subjects of History, Government, Geography,
Economics, Civics, or non -Western culture and approved for college
admission requirements;
5. Two units or sets of competencies of the same world or non -
English language or two units of computer technology approved for
college admission requirements, whether taught at a high school or a
technology center school, including computer progra mming, hardware,
and business computer applications, such as word processing,
databases, spreadsheets, and graphics, excluding keyboarding or
typing courses;
6. One additional unit or set of competencies selected from
paragraphs 1 through 5 of this subsec tion or career and technology
education courses, concurrently enrolled courses, Adva nced Placement
courses or International Baccalaureate courses approved for college
admission requirements; and
7. One unit or set of competencies of fine arts, such as mus ic,
art, or drama, or one unit or set of competencies of speech.
C. In lieu of the requirements of subsection B of this section
which requires a college preparatory/work ready curriculum, a
student may enroll in the core curriculum a s provided in subsection
D of this section upon written approval of the parent or le gal
guardian of the student. For students under the age of eighteen
(18) school districts shall require a parent or legal guardian of
the student to meet with a designee o f the school prior to
enrollment in the core curriculum. The State Department of
Education shall develop and distribute to school districts a form ENR. H. B. NO. 1041 Page 5
suitable for this purpose, which shall include information on the
benefits to students of completing the col lege preparatory/work
ready curriculum as provided for in subsection B of this secti on.
D. For those students subject to the requirements of subsection
C of this section, in order to graduate from a public high school
accredited by the State Board of Educ ation with a standard diploma,
students shall complete the following core curriculum units or sets
of competencies at the secondary level:
1. Language Arts – Four units or sets of competencies, to
consist of one unit or set of competencies of grammar and
composition, and three units or sets of competencies which may
include, but are not limited to, the following courses:
a. American Literature,
b. English Literature,
c. World Literature,
d. Advanced English Courses, or
e. other English courses with content and/or rigor equal
to or above grammar and composition;
2. Mathematics – Three units or sets of competencies to consist
of one unit or set of competencies of Algebra I or Algebra I taught
in a contextual methodology, and two u nits or sets of competencies
which may include, but are not limited to, the following courses:
a. Algebra II,
b. Geometry or Geometry taught in a contextual
methodology,
c. Trigonometry,
d. Math Analysis or Precalculus,
e. Calculus,
f. Statistics and/or Pr obability,
ENR. H. B. NO. 1041 Page 6
g. Computer Science or acceptance and successful
completion of one (1) year of a full -time, three-hour
career and technology program leading to an industry
credential/certificate or college credit. The State
Board of Career and Technology Educa tion shall
promulgate rules to define the provisions of this
section related to the accepted industr y-valued
credentials which are industry-endorsed or industry-
aligned. The list of accepted industry -valued
credentials shall be reviewed annually and updat ed at
least every three (3) years by the Board,
h. (1) contextual mathematics courses which enhance
technology preparation, or
(2) a science, technology, engineering and math
(STEM) block course meeting the requirements for
course competencies listed in pa ragraph 2 of
subsection B of this section, whether taught at
a:
(a) comprehensive high school, or
(b) technology center school when ta ken in the
tenth, eleventh or twelfth grade, taught by
a certified teacher, and approved by the
State Board of Education a nd the independent
district board of education,
i. mathematics courses taught at a technology c enter
school by a teacher certified in the secondary subject
area when taken in the tenth, eleventh or twelfth
grade upon approval of the State Board of Educatio n
and the independent distri ct board of education, or
j. any other mathematics course with con tent and/or rigor
equal to or above Alge bra I;
3. Science – Three units or sets of competencies to consist of
one unit or set of competencies of Biology I or Bio logy I taught in
a contextual methodology, and two units or sets of competencies in
the areas of life, physical, or earth science or t echnology which
may include, but are not limited to, the following courses:
a. Chemistry I, ENR. H. B. NO. 1041 Page 7
b. Physics,
c. Biology II,
d. Chemistry II,
e. Physical Science,
f. Earth Science,
g. Botany,
h. Zoology,
i. Physiology,
j. Astronomy,
k. Applied Biology/Chemistry,
l. Applied Physics,
m. Principles of Technology,
n. qualified agricultural education courses,
o. (1) contextual science courses which enhance
technology preparation, or
(2) a science, technology, en gineering and math
(STEM) block course meeting the requir ements for
course competencies listed in paragraph 3 of
subsection B of this section, whether taught at
a:
(a) comprehensive high school, or
(b) technology center school when taken in the
tenth, eleventh or twelfth grade, taught by
a certified teacher, and approved by the
State Board of Education and the independent
district board of education,
ENR. H. B. NO. 1041 Page 8
p. science courses taught at a technology center school
by a teacher certified in the secondary subject a rea
when taken in the tenth, eleventh or twelfth grade
upon approval of the State Board of Education and the
independent district board of education, or
q. other science courses w ith content and/or rigor equal
to or above Biology I;
4. Social Studies – Three units or sets of competencies, to
consist of one unit or set of competencies of United States History,
one-half to one unit or set of competencies of United States
Government, one-half unit or set of compet encies of Oklahoma
History, and one-half to one unit or set of competencies which ma y
include, but are not limited to, the following courses:
a. World History,
b. Geography,
c. Economics,
d. Anthropology, or
e. other social studies courses with content and /or rigor
equal to or above United Stat es History, United States
Government, and Oklahoma History;
5. Arts – One unit or set of competencies which may include,
but is not limited to, courses in Visual Arts and Genera l Music; and
6. Computer Education or World Language - One unit or set of
competencies of computer technology, whether tau ght at a high school
or a technology center school, including computer programming,
hardware and business computer applications, such as word
processing, databases, spreads heets and graphics, excluding
keyboarding or typing courses, or one unit or set of c ompetencies of
world or non-English language.
E. A school district may issue an alternate diploma to a
student who meets the definition of a student with the most
significant cognitive disabilities and who participates in the
Oklahoma Alternate Assessment Program (OAAP) beginning in the 2023-
2024 school year. An alternate diploma shall be standards-based,
aligned with requirements for a standard diploma, and obtained by ENR. H. B. NO. 1041 Page 9
the school year in which a student turns twenty-two (22) years of
age.
F. An alternate diploma shall not terminate a Free and
Appropriate Public Education (FAPE) for students with an
Individualized Education Program (IEP) unless they reach the maximum
age of FAPE. The IEP team shall determine subsequent courses and
services for students who receive an alternat e diploma.
G. Students participating in the OAAP shall not be precluded
from attempting to meet the requirements of a standard diploma and
participation in the OAAP shall not determine a student's
educational setting under the Individuals with Disabilitie s
Education Act (IDEA).
H. Students who meet requirements for an alternate diploma may
count as having received a standard diploma for purposes of
calculating and reporting the adjusted cohort graduation rate
(ACGR).
I. A student may be awarded an alternate diploma upon
completion of the following curriculum units or sets of competencies
at the secondary level:
1. Language Arts – Four units or sets of competencies based on
alternate academic achievement standards to consist of reading
literature, reading informational text, writing, speaking and
listening, and language in the following courses :
a. English 1 Alternate,
b. English 2 Alternate,
c. English 3 Alternate, and
d. English 4 Alternate;
2. Mathematics – Three units or sets of competencie s based on
alternate academic achievement standards to consist of number,
quantities, algebra, functions /statistics, probability, and geometry
in the following courses:
a. Math Alternate 1,
b. Math Alternate 2, and ENR. H. B. NO. 1041 Page 10
c. Math Alternate 3;
3. Science – Three units or sets of competencies based on
alternate academic achievement standards to consist of life science,
physical science, and earth science in the fo llowing courses:
a. Life Science Alternate,
b. Physical Science Alternate, and
c. Earth Science Alternate;
4. Social Studies – Three units or sets of competencies based
on alternate academic achievement standards to consist of United
States History, United States Government, Oklahoma History,
Geography, and Social Studies in the following courses:
a. Social Studies Alternate 1 ,
b. Social Studies Alternate 2 , and
c. Social Studies Alternate 3;
5. Arts – One unit or set of competencies which may include ,
but is not limited to, courses in Visual Arts and General Music;
6. Computer Education or World Language - One unit or set of
competencies of computer technology, whether taught at a high school
or a technology center school , including computer programm ing,
hardware, and business computer applications, such as w ord
processing, databases, spreadsheets, and graphics, excluding
keyboarding or typing courses, or one unit or set of competencies of
world or non-English language;
7. Career Readiness – at least two units of Career Re adiness,
including Career Readiness I, Career Rea diness II, Career Readiness
III, or Career Readiness IV. Each Career Readiness course may be
substituted for Careers/Exploration, Internship I, or Internship II ;
and
8. Life Skills – at least two units of Life Skills, such as
Life Skills I, Life Skills II, Life Skills III, or Life Skills IV.
Each Life Skills cour se may be substituted for the Life Skills or
Family and Consumer Science courses. ENR. H. B. NO. 1041 Page 11
J. Courses in the core curriculum may be used as a substitute
for corresponding courses required by the alternate diploma. Other
courses may be substituted as determined by the State Board of
Education.
K. 1. In addition to the curriculum requirements of either
subsection B or D of this section, in order to grad uate from a
public high school accredited by the State Board of Education
students shall complete the req uirements for a personal financial
literacy passport as set forth in the Passport to Financial Literacy
Act and any additional course requirements or r ecommended elective
courses as may be established by the State Board of Education and
the district school board. School districts shall strongly
encourage students to complete two units or sets of competencies of
world languages and two units or sets of c ompetencies of physical
and health education.
2. No student shall receive credit for high school graduat ion
more than once for completion of the same unit or set of
competencies to satisfy the curriculum requirements of this secti on.
3. A school district shall not be required to offer every
course listed in subsections B and D of this section but shall offe r
sufficient courses to allow a student to me et the graduation
requirements during the secondary grade years of the student.
F. L. 1. In addition to the curriculum requirements of either
subsection B or D of this section, beginning with ninth graders in
the 2021-22 school year, in order to graduate from a public high
school accredited by the State Board of Education, students shal l
pass the United States naturalization test pursuant to the
provisions of this subsection.
2. School districts shall offer th e United States
naturalization test to studen ts at least once per school year,
beginning as early as eighth grade at the discreti on of the school
district; provided, any student may retake the exam upon request,
and as often as desired, until earning a pas sing score. For
purposes of this subsection, a passing score shall be 60 out of 100
questions.
3. School districts shall exempt students with disabilities
whose individualized education program (IEP), consistent with state
law, indicates that the student is to be assessed with alternate ENR. H. B. NO. 1041 Page 12
achievement standards through the Oklahoma Alternate Assessment
Program (OAAP) OAAP.
G. M. For purposes of this section:
1. "Contextual methodology" means academic content and skills
taught by utilizing real -world problems and projects in a way that
helps students under stand the application of that knowledge;
2. "Qualified agricultural education courses " means courses
that have been determined by the State Board of Education to offer
the sets of competencies for one or more s cience content areas and
which correspond to academic science courses. Qualified
agricultural education courses shall include, but are not limited
to, Horticulture, Plant and Soil Science, Natural Resources and
Environmental Science, and Animal Science. The courses shall be
taught by teachers certi fied in agricultural education and comply
with all rules of the Oklahoma Department of Career and Technology
Education;
3. "Rigor" means a level of difficulty that is thorough,
exhaustive and accurate and is ap propriate for the grade level;
4. "Sets of competencies" means instruction in those skills and
competencies that are specified in t he subject matter standards
adopted by the State Board of Education and other skills and
competencies adopted by the Board, without regard to specified
instructional time; and
5. "Unit" means a Carnegie Unit as defined by the North Central
Association's Commission on Schools.
H. N. 1. The State Board of Education shall adopt a plan to
ensure that rigor is maintained in the c ontent, teaching
methodology, level of expect ations for student achievement, and
application of learning in all the courses taught to meet the
graduation requirements as specified in this section.
2. The State Board of Education shall allow as much flexib ility
at the district level as is possible wi thout diminishing the rigor
or undermining the intent of providing these courses. To ac complish
this purpose, the State Department of Education shall work with
school districts in reviewing and approving course s taught by
districts that are not specifical ly listed in subsections B and D of
this section. Options may include, but shall not be limited to, ENR. H. B. NO. 1041 Page 13
courses taken by concurrent enrollment, advanced placement, or
correspondence, or courses bearing different ti tles.
3. The State Board of Education shall approve an advanced
placement computer science course to meet the requirements of cours e
competencies listed in paragraph 2 of subsection B of this section
if the course is taken in a student 's senior year and the student is
concurrently enrolled in or has successfully completed Algebra II.
4. Technology center school districts may offer p rograms
designed in cooperation with institutions of higher education which
have an emphasis on a focused field of career stu dy upon approval of
the State Board of Educat ion and the independent district board of
education. Students in the tenth grade may be allowed to attend
these programs for up to one-half (1/2) of a school day and credit
for the units or sets of competencies required in paragraphs 2, 3
and 6 of subsection B or D of this section shall be given if the
courses are taught by a teacher certi fied in the secondary subject
area; provided, credit for units or sets of competencies pursuant to
subsection B of this secti on shall be approved for college admission
requirements.
5. If a student enrolls in a concurrent course, the school
district shall not be responsible for any costs incurred for that
course, unless the school district does not offer enough course
selection during the student's secondary grade years t o allow the
student to receive the courses needed to meet the graduation
requirements of this section. If the school district does not offer
the necessary course selection during the student 's secondary grade
years, it shall be responsible for the cost of resident tuition at
an institution in The Oklahoma State System of Higher Education,
fees, and books for the concurrent enrollment course, and providing
for transportation to and from the institution to the sch ool site.
It is the intent of the Legislature that for students enrolled
in a concurrent enrollment course which is paid for by t he school
district pursuant to this paragraph, the institution charge only the
supplementary and special service fees that are directly related to
the concurrent enrollment course and enrollment procedures for that
student. It is further the intent of the Legislature that fees for
student activities and student service facilities, including the
student health care and cultural an d recreational service fees, not
be charged to such students.
ENR. H. B. NO. 1041 Page 14
6. Credit for the units or sets of competencies required in
subsection B or D of this section shall be given when such units or
sets of competencies are taken prior to ninth grade if the teache rs
are certified or authorized to teach the s ubjects for high school
credit and the required rigor is maintained.
7. The three units or sets of competencies in mathematics
required in subsection B or D of this section shall be completed in
the ninth through twelfth grades. If a student completes an y
required courses or sets of competencies in mathematics prior to
ninth grade, the student may take any other mathematics courses or
sets of competencies to fulfill the requirement to complete three
units or sets of competencies in grades nine through twe lve after
the student has satisfied the requirements of subsection B or D of
this section.
8. All units or sets of competencies required for graduation
may be taken in any sequence recommended by the school dis trict.
I. O. As a condition of receiving acc reditation from the State
Board of Education, all students in grades nine throug h twelve shall
enroll in a minimum o f six periods, or the equivalent in block
scheduling or other scheduling structure that allows for instruction
in sets of competencies, of r igorous academic and/or rigorous
vocational courses each day, which may include arts, vocal and
instrumental music, speech classes, and physical education classes.
J. P. 1. Academic and vocational -technical courses designed to
offer sets of competencies integrated or embedded within the courses
that provide for the teaching and lea rning of the appropriate skills
and knowledge in the subject matter standards, as adopted by the
State Board of Education, may, upon approval of the Board, in
consultation with the Oklahoma Department of Career and Technology
Education if the courses are o ffered at a technology center school
district, be counted for academic credit and toward meeting the
graduation requirements of this section.
2. Internet-based courses offered by a technology center school
that are taught by a certified teacher and provi de for the teaching
and learning of the appropriate skills and knowledge in the subject
matter standards may, upon approval of the St ate Board of Education
and the independent di strict board of education, be counted for
academic credit and toward meeting t he graduation requirements of
this section.
ENR. H. B. NO. 1041 Page 15
3. Internet-based courses or vocational -technical courses
utilizing integrated or embedd ed skills for which no subject matter
standards have been adopted by the State Board of Education may be
approved by the Board, in consultation with the Oklahoma Department
of Career and Technology Education if the courses are offered at a
technology center school district, if such courses incorporat e
standards of nationally recognized professional organizations and
are taught by certified teachers.
4. Courses offered by a supplemental education organization
that is accredited by a national accrediting bod y and that are
taught by a certified teacher and provide for the teaching and
learning of the appropriate skills and know ledge in the subject
matter standards may, upon approval of the State Board of Education
and the school district board of education, be counted for academic
credit and toward meeti ng the graduation requirements of this
section.
K. Q. The State Board of E ducation shall provide an option for
high school graduation based upon attainment of the desired levels
of competencies as required in t ests pursuant to the provisions of
Section 1210.508 of this title. Such option shall be in lieu of the
amount of course credits earned.
L. R. The State Board of Education shall prescribe, adopt and
approve a promotion system based on the attainment by st udents of
specified levels of competencies in each area of the core
curriculum.
M. S. Children who have individualized education programs an
IEP pursuant to the Individuals with Disabilities Education Act
(IDEA) IDEA, and who satisfy the graduation requireme nts through the
individualized education program for that student shall be awarded a
standard diploma.
N. T. Students who enter the ninth grade in or prior t o the
2007-08 school year who are enrolled in an alternative education
program and meet the requir ements of their plans leading to hi gh
school graduation developed pursuant to Section 1210.568 of this
title shall be awarded a standard diploma.
O. U. Any student who completes the curriculum requirements of
the International Baccalaureate Diploma Progra m shall be awarded a
standard diploma.
ENR. H. B. NO. 1041 Page 16
P. V. Any student who successfully completes an advanced
mathematics or science course offered pursuant to Section 121 0.404
of this title shall be granted academic credit toward meeting the
graduation requirements pu rsuant to paragraph 2 or 3, as
appropriate, of subsection B or D of this section.
Q. W. For purposes of this s ection, the courses approved for
college admission requirements shall be courses which are approved
by the Oklahoma State Regents for Higher Educ ation for admission to
an institution within The Oklahoma State System of Higher Education.
R. X. Students who have been denied a standard diploma by the
school district in which the student is or was enrolled for failing
to meet the requirements of this section may re-enroll in the school
district that denied the student a standard diploma following the
denial of a standard diploma. The student shall be prov ided
remediation or intervention and the opportunity to complete the
curriculum units or sets of c ompetencies required by this section to
obtain a standard diploma. Students who re-enroll in the school
district to meet the graduation requirements of this section shall
be exempt from the hourly instructional requirements of Section 1 -
111 of this title and the six-period enrollment requirements of t his
section.
S. Y. The State Department of Education shall co llect and
report data by school site and district on the number of students
who enroll in the core curriculum as provided in subsection D of
this section.
SECTION 2. This act shall become effective July 1, 2023.
SECTION 3. It being immediately necessary for the preservation
of the public peace, health or safety, an emergency is hereby
declared to exist, by reason whe reof this act shall take effect and
be in full force from and after its passage and approval.
ENR. H. B. NO. 1041 Page 17
Passed the House of Representatives the 8th day of March, 2023.
Presiding Officer of the House
of Representatives
Passed the Senate the 17th day of April, 2023.
Presiding Officer of the Senate
OFFICE OF THE GOVERNOR
Received by the Office of the Governor this ____________________
day of ___________________, 20_______, at _______ o'clock _______ M.
By: _________________________________
Approved by the Governor of the State of Oklahoma this _____ ____
day of ___________________, 20_______, at ______ _ o'clock _______ M.
_________________________________
Governor of the State of Oklahoma
OFFICE OF THE SECRETARY OF STATE
Received by the Office of the Secretary of State this __________
day of ___________________, 20_______, at _______ o'clock ______ _ M.
By: _________________________________