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Sample Cover Sheet Designating and Independent Petitions [ Place Name of Party or Independent Body Here ] Name of Candidate Residence Address (Also mailing address if different) Public Office or Party Position (Include district number where appropriate) Volume Number Total Number of Volumes in Petition The petition contains the number, or in excess of the number, of valid signatures required by Election Law. Contact Person to Correct Deficiencies: Name (Please print) Residence Address (Also mailing address if different) Phone Fax (Include if notice by fax desired) Email (Include if notice by email desired) I hereby authorize that any notice of any determination made by the Board of Elections be transmitted to the person named above. Optional: For candidates for statewide office, Member of Assembly or State Senator only The following website address is submitted to be published on the state board of elections website pursuant to Election Law § 4-123 for the candidate listed opposite: Name of Candidate Website Address Signature of Candidate or Agent (Sample prepared by the State Board of Elections) Cover Sheet (DI) – 01.2018 ---PAGE BREAK--- Sample Cover Sheet Designating and Independent Petitions Filed In New York City and Counties Which Utilize Petition Identification Numbering Systems [ Place Name of Party or Independent Body Here ] Name of Candidate Residence Address (Also mailing address if different) Public Office or Party Position (Include district number where appropriate) Total Number of Volumes in Petition Identification Numbers The petition contains the number, or in excess of the number, of valid signatures required by Election Law. Contact Person to Correct Deficiencies: Name (Please print) Residence Address (Also mailing address if different) Phone Fax (Include if notice by fax desired) Email (Include if notice by email desired) I hereby authorize that any notice of any determination made by the Board of Elections be transmitted to the person named above. Optional: For candidates for statewide office, Member of Assembly or State Senator only The following website address is submitted to be published on the state board of elections website pursuant to Election Law § 4-123 for the candidate listed opposite: Name of Candidate Website Address Signature of Candidate or Agent (Sample prepared by the State Board of Elections) Cover Sheet (DI-NYC) – 01.2018