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OTB – 01.2018 (Sample prepared by the State Board of Elections) Sheet No. Opportunity to Ballot Petition Sec. 6-132 and 6-166, 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, that my place of residence is truly stated opposite my signature hereto, and I do hereby request an opportunity to write in the name of an undesignated candidate or candidates for nomination to the public office or offices or for election to the party position or positions, in the political unit or units of representation hereinafter set forth, of such party to be voted on the day of Public Office or Party Position Political Unit or Unit of Representation I do hereby appoint as a committee to receive notices 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 enrolled voters of said party): 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 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 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