Village Designating Petition Template
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1Village Designating Petition
Sec 6-204, ELECTION LAW
I, the undersigned, do hereby state that I am a registered voter of the Village of ________________________________, and a
duly enrolled voter of the _________________________________Party and entitled to vote in the next primary election of such
party, 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 public offices) to be
voted for at the primary election to be held on the _____ day of _______________________, 20______, as hereinafter specified.
Name(s) of Candidate(s)
Public Office
Term
Residence
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 WITNESS WHEREOF, 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.)
STATEMENT OF WITNESS
I (name of witness)
state: I am a duly qualified voter of the State of
New York; and an enrolled voter of the
Party and now reside in the Village of
, County of
State of New York, at
(residence address) therein.
Each of the persons whose names are subscribed to this petition sheet containing
signatures, subscribed his or her
name in my presence.
I understand that this statement will 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 Witness
NOTARY PUBLIC
(This can be used only if the election is conducted by the county board of elections.)
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
E
Sheet No.
S VIL-b (6/2007)
(Sample prepared by the State Board of Elections)
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