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CERTIFICATE OF DECLINATION (Section 6-146, Election Law) I, , residing at (Candidate’s Name) (Address) having been designated/nominated by the (Name of Party) Party, as a candidate for the office of (Title of Office and Political Subdivision) district, at a (District Number if any) (Special/Primary/General) election to be held on , 20 , do hereby DECLINE such designation/nomination. (Date) (Signature of Candidate) State of New York : County of : ss: On this day of , 20 , before me personally appeared , to me known and known to me to be the individual described therein, and who executed the foregoing instrument, and acknowledged to me that he/she executed the same. Notary Public (Sample Prepared by State Board of Elections) Rev. 04/2012