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Village Independent Nominating Petition Sec. 15-108, ELECTION LAW I, the undersigned, do hereby state that I am a registered voter of the Village of that my present place of residence is truly stated opposite my signature hereto, and that I do hereby nominate the following named person (or persons) as a candidate (or candidates) for election to public office (or public offices) to be voted for at the election to be held on the day of 20 and that I select the name (fill in name) as the name of the independent body making the nomination (or nominations) and (fill in emblem) as the emblem of such body. 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 such political unit), 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 (signature required) Residence Enter Town or City (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, state that I am a duly qualified voter and now reside at (Residence Address), in the Village of in the State of New York in the County of Each of the voters whose names are subscribed to this petition sheet, containing (fill in number) 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 ES VIL-a (6/2007) (Sample prepared by the State Board of Elections) Sheet No.