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Independent Nominating Petition Sec. 6-140, Election Law I, the undersigned, do hereby state that I am registered voter of the political unit for which a nomination for public office is hereby being made, 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 Residence Address (Include district number, if applicable) (Also post office address if not identical) I do hereby appoint as a committee to fill vacancies in accordance with the provisions of the election law (here insert the names and addresses of at least three persons, all of whom shall be registered voters within said political unit): In witness whereof, I have hereunto set my hand, the day and year placed opposite my signature. Date Name of Signer (Signature required. Printed name may be added) Residence Enter Town or City (Except in NYC enter county) 1. / / 20___ Printed Name 2. / / 20___ Printed Name 3. / / 20___ Printed Name 4. / / 20___ Printed Name 5. / / 20___ Printed Name (You may use fewer or more signature lines - this is only to show format.) Complete ONE of the following 1. Statement of Witness: I (name of witness) state: I am a duly qualified voter of the State of New York. 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 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 Witness Identification Information: 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 Where Witness Resides County Where Witness Resides 2. Notary Public or Commissioner 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 INP – 01.2018 (Sample prepared by the State Board of Elections) Sheet No.