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VILLAGE INDEPENDENT NOMINATING PETITION Sec. 6-206, ELECTION LAW I, the undersigned, do hereby state that I am a registered voter of the Village of 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 and that I select the name (fill in the name) as the name of the independent body making the nomination (or nominations) and (fill in emblem) the emblem of such body. Name(s) of Candidate(s) Public Office Term Residence I do hereby appoint (insert names & addresses of at least three persons, all of whom shall be enrolled voters of such political unit), 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 Residence Town or City Complete ONE of the following 1) STATEMENT OF WITNESS I, (name of witness) state that I am duly qualified voter and now reside (Residence Address), in the Village of in the State of New York in the County of Each of the voters 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 2) NOTARY PUBLIC (This can be used only if the election is conducted by the County Board of Elections.) On the dates indicated before me personally came each of the voters whose signatures appear on this petition sheet containing (fill in the 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 Administrating Oath ES-27c(6/2007) Sheet No.