Each page of a nominating petition submitted to the town clerk or the Secretary of the State and filed with the Secretary of the State under the provisions of sections 9-453a to 9-453s, inclusive, or § 9-216 shall contain a statement as to the residency in this state and eligibility of the circulator and authenticity of the signatures thereon, signed under penalties of false statement, by the person who circulated the same. Such statement shall set forth (1) such circulator’s residence address, including the town in this state in which such circulator is a resident, (2) the circulator’s date of birth and that the circulator is at least eighteen years of age, (3) that the circulator is a United States citizen and not on parole for conviction of a felony, and (4) that each person whose name appears on such page signed the same in person in the presence of such circulator and that either the circulator knows each such signer or that the signer satisfactorily identified himself to the circulator. Any false statement committed with respect to such statement shall be deemed to have been committed in the town in which the petition was circulated.