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Village Designating Petition Sec15-108, ELECTION LAW I, the undersigned, do hereby state that I am a registered voter of the Village of and a duly enrolled voter of the and entitled to vote in the next primary election of such party, that my place of residence is truly stated opposite my signature hereto, and I do hereby designate the following named person (or persons) as a candidate (or candidates) for the nomination of such party for public office (or public offices) to be voted for at the primary election to be held on the day of as hereinafter specified. 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 said party), 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 (name of witness) state: I am a duly qualified voter of the State of New York; and an enrolled voter of the party and now reside in the Village of , State of New York, at. (residence address) therein. Each of the individuals 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-d (6/2007) (Sample prepared by the State Board of Elections) Sheet No.