Es 26a - Designating Petition Template

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Designating Petition
Sec. 6-132, ELECTION LAW
I, the undersigned, do hereby state that I am a duly enrolled voter of the ________________________________ Party and
entitled to vote at the next primary election of such party, to be held on _________________________, 20______; that my place
of residence is truly stated opposite my signature hereto, and I do hereby designate the following named person (or persons) as
a candidate (or candidates) for the nomination of such party for public office or for election to a party position of such party.
)
Name(s) of Candidate(s)
Public Office or Party Position
Place of Residence (also Post Office address if not identical
I do hereby appoint (here insert the names and addresses of at least three persons, all of whom shall be enrolled voters of said party),
as a committee to fill vacancies in accordance with the provisions of the election law.
IN W ITNESS W HEREOF, I have hereunto set my hand, the day and year placed opposite my signature.
Date
Name of Signer
Residence
Enter Town or City
(signature required)
(printed name may be added)
Except in NYC enter County
1.
/
/
Printed Name
2.
/
/
Printed Name
3.
/
/
Printed Name
4.
/
/
Printed Name
5.
/
/
Printed Name
6.
/
/
Printed Name
7.
/
/
Printed Name
8.
/
/
Printed Name
9.
/
/
Printed Name
10.
/
/
Printed Name
(You may use fewer or more signature lines - this is only to show format.)
Complete ONE of the following
1) STATEM ENT OF W ITNESS
I (name of witness)
state: I am a duly qualified voter of the State of New York
and am an enrolled voter of the
Party.
I now reside at (residence address)
.
Each of the individuals whose names are subscribed to this petition sheet containing (fill in number)
signatures, subscribed
the same in my presence on the dates above indicated and identified himself or herself to be the individual who signed this sheet.
I understand that this statement w ill be accepted for all purposes as the equivalent of an affidavit and, if it contains a material false
statement,, shall subject me to the same penalties as if I had been duly sworn.
Date
Signature of W itness
W ITNESS IDENTIFICATION INFORM ATION: The following information for the witness named above must be completed prior
to filing with the board of elections in order for this petition to be valid.
Town or City
County
2) NOTARY PUBLIC OR COM M ISSIONER OF DEEDS
On the dates above indicated before me personally came each of the voters whose signatures appear on this petition sheet
containing (fill in number)
signatures, who signed same in my presence and who, being by me duly sworn, each for himself
or herself, said that the foregoing statement made and subscribed by him or her was true.
Date
Signature and Official Title of Officer Administering Oath
Sheet No.
ES 26a (6/2007)
(Sample prepared by the State Board of Elections)

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