SECTION 1

Date Stamp Independent Nominating Petition

Sec. 6-140, Election Law I, the undersigned, do hereby state that I am registered voter of the political unit for which a nomination for public office is hereby being made, 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 6 day of November, 2018, and that I select the

name (fill in name) Fun for All as the name of the independent body making the

nomination (or nominations) and (fill in emblem) as the emblem of such body.

Name(s) of Candidate(s) Public Office

(Include district number, if applicable) Residence Address

(Also post office address if not identical)

Mickey Mouse

Bath Town Justice

4 Year Term

1 Disney Way, Bath NY 14810

PO Box 111, Bath NY 14810

I do hereby appoint as a committee to fill vacancies 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 registered voters within said political unit):

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

SECTION 2

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

1. 7/15/2018 Donald Duck 7 Disney Way Apt 101 Bath 2.

7/24/2018 Ted Chipmunk 4 Tree House Lane Bath TC 7/24/18

3. 7/24/2018 Theodore Chipmunk 4 Tree House Lane

Bath

SECTION 3 4.

/ /20___

5. / /20___

Complete ONE of the following

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 sheet to be valid.

___________________________ __________________________ Town or City Where Witness Resides County Where Witness Resides

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) __________

signature’s, 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 of Official Title

of Officer Administering Oath

Sheet Number: _________

SECTION 4

A

D

E

A

B

C

D

F

A

CANDIDATES ONLY

Don’t forget to number the sheets before filing them if you have more than one sheet.

NOTARY STAMP

E

SECTION 5

B

F

E

B

01.2018

Independent Petition

NOTE: All petitions are assumed to be valid when filed

SECTION #1 – Date of Election, Party Name & Emblem, Your Name, Office & Address

The Date of the General Election must be entered at the top of the petition.

Choosing a party name & Emblem. Election Law §2-124, (Needed for ballot purposes)

(i.e.: Fun for All) the name can only be fifteen letters including spacing to fit on the ballot. There are

certain words you cannot use in your party name (i.e.: American, United States, NYS) your emblem for

the petition should be picked out from the list at the Board of Elections Office. Party names must be

registered with the Election office so it is not duplicated.

Name of Candidate (Your name); a candidate may use his/her name adopted in good faith and by which he/she

is recognized in the community. Election Law §7-102, the way your name will appear on the ballot

Name of Town, Office Title and Term of Office in which the candidate is running (Ex: 1yr unexpired vs. 2 or 4 yr. full term)

Enter RESIDENCE ADDRESS and PO Box if applicable.

SECTION #2 – Vacancy Committee

The failure to list a committee to fill vacancies shall not be a fatal defect. Election Law §6-134(8) However, if a

vacancy occurs which may be filled by a committee of vacancies and no committee is listed, the petition fails and

the vacancy cannot be filled.

At least three (3) members are needed to form a vacancy committee.

You must live in the district to be on a vacancy committee. Election Law §6.140

SECTION #3 – Signatures

a) The signer is anyone who is registered to vote in your town, regardless of party affiliation. They can sign your

petition as long as they have not already signed a petition for the same office. A voter can only sign the number

of petitions that there are offices up for elections. (i.e. 2 Town Councilmen, they can only sign (2) petitions for

that office.)

b) An alteration or correction of information appearing on a signature line, other than the signature itself and the date shall not invalidate the signature. Section §6-134.6

c) If making corrections in the “Residence or Town or City” section of petition, draw only one line through it to

correct. All corrections made on a petition must be initialed & dated. No unexplained alteration should be

made to the petition or any information on it.

d) Do Not use White-Out on petitions. If a mistake is made on the “Date” or “Signature”, draw a line through the

entire row initial it, then start again on the next line.

e) “Town or City” refers to the signer’s voting district, not his or her mailing address. For example, a mailing

address may be “Hornell, NY” but the voting district is “Hornellsville”

SECTION #4 – Statement of Witness

The witness statement must be filled out before entering the Board of Elections for filing.

a. The Person carrying the petition door to door gathering the signatures is the witness. The Statement of Witness

section must list the name of the witness.

b. The witness must state the party they are a registered voter of. The witness must be an enrolled voter of the party

that the petition is for. However, a Notary Public can carry a petition regardless of party affiliation. (See Notary

Statement on the back)

c. The witness must provide their residential address and be a registered voter in the State of New York.

d. The number of signatures on the petition must be stated in the witness statement. (If challenged, the failure to

state the number can result in the petition page being thrown out.)

Continued on next page

01.2018

e. The witness must sign and date the Statement of Witness. This should be done when you are done carrying the

petitions. You cannot witness your own signature.

f. Town or City: ______ & County: _______ applies to where the witness resides.

As a witness (i.e. carrier of a petition) you cannot sign a petition for the same office. This is true regardless of whether

it is for a different candidate, or the same candidate, also running on an independent line for the same office. If you

have signed a designating petition, then you cannot carry an independent petition.

SECTION #5 - Notary Public or Commissioner of Deeds

This section only needs to be completed when an individual witnessing signatures on a petition is a

Notary Public or a Commissioner of Deeds. The Notary Public must administer an oath to each signer

that they witness signing the petition.

a) The Notary/Commissioner of Deeds section must state the number of signatures on the petition.

b) The Notary/Commissioner of Deeds must include their signature, notary/commissioner of deed stamp,

expiration date, and the date they signed the form.

SHEET NUMBER

All petition sheets must be attached together. Sheets must be numbered in consecutive order. If you are

carrying a petition for a candidate, it is best to leave this section blank for the candidate to complete

before filing of the petitions.

FILING OF PETITION State Board Rule §6215.1

1. If you have (2) or more sheets for your petition, the sheets must be numbered sequentially.

(Failure to number petitions will invalidate the petition)

2. Petition sheets must be fastened together (i.e. stapled) or by any means which it will hold the pages

together in numerical order (NO PAPER CLIPS).

[[[3 “Certificate of Acceptance” must be filed with an Independent petition. Election Law §6-146.4

COVER SHEETS

State Board Rule §6215.2

If you have 10 or more sheets, you must have a completed cover sheet securely attached to the front of

each volume of petitions. The BOE has blank covers sheets available.

CORRECTIONS

State Board Rule §6215.7

Within two (2) business days of the receipt of the petition, the board shall review the petition to

determine whether the petition complies with requirements set by the State Board of Elections.

After which the Commissioners will notify the candidate by overnight mail or fax of the errors,

some errors can be corrected

The candidate will have three (3) business days of the date of the determination to cure any

violation that is curable.

Cover sheet deficiencies maybe corrected by the filing of an amended cover sheet. Such cure or

correction must be received by the Board of Elections no later than the third (3rd

) business day

following such determination.

If a petition contains fatal flaws such as not stating the proper office or municipality, it is not

curable.

You can track Petition filings, Caucus filings and Challenges on our website at:

www.steubencony.org/boe