§ 6-140. Independent nominations; form of petition. 1. a. Each sheet
of an independent nominating petition shall be signed in ink, shall
contain the following information and shall be in substantially the
following form:

I, the undersigned, do hereby state that I am a 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 as candidates) for election to
public office (or public offices) to be voted for at the election to be
held on the ............ day of ................, 20...., and that I
select the name ............................ (fill in name) as the name
of the independent body making the nomination (or nominations) and
................. (fill in emblem) as the emblem of such body.

Public Place of residence

Office (also post office
Name of (include district address
Candidate number, if applicable) if not identical)
.......... ................. ..........................
.......... ................. ..........................
I do hereby appoint ............................. (here insert the names
and addresses of at least three persons, all of whom shall be registered
voters within 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 (except

in the city of New

York, the county)

.......................

.......................

b. There shall be appended at the bottom of each sheet a signed
statement of a witness who is a duly qualified voter of the state and
who has not previously signed a petition for another candidate for the
same office. Such a statement shall be accepted for all purposes as the
equivalent of an affidavit, and if it contains a material false
statement, shall subject the person signing it to the same penalties as
if he or she had been duly sworn. The form of such statement shall be
substantially as follows:

STATEMENT OF WITNESS

I, ...................... (name of witness) state: I am a duly
qualified voter of the State of New York and 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 must be completed prior to filing with the
board of elections in order for this petition sheet to be valid.

Town or City County

............... .........

2. In lieu of the signed statement of a witness who is a duly
qualified voter of the state, the following statement signed by a notary
public or commissioner of deeds shall be accepted:

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)

3. The state board of elections shall prepare a sample form of an
independent nominating petition which meets the requirements of this
section and shall distribute or cause such forms to be distributed to
each board of elections. Such forms shall be made available to the
public upon request, by the state board of elections and each such
board. Any petition that is a copy of such a sample shall be deemed to
meet the requirements of form imposed by this section.