Designating Petition Sec. 6-132, 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, to be held on ____________________, 20 ; 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 for election to a party position of such party.
Name(s) of Candidate(s) Public Office or Party Position Residence Address
(Include district number, if applicable) (Also post office address if not identical)
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 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
DP – 01.2018 (Sample prepared by the State Board of Elections) Sheet No. __________
