STATE OF NEW YORK PUBLIC EMPLOYMENT RELATIONS BOARD PETITION FOR DECLARATORY RULING INSTRUCTIONS: File an original and four (4) copies of this Petition with the Director of Public Employment Practices and Representation, New York State Public Employment Relations Board, PO BOX 2074, ESP AGENCY BLDG 2, ALBANY, NY 12220-0074. If more space is required for any item, attach additional sheets, numbering item accordingly. DO NOT WRITE IN THIS SPACE Case No. DRDate Received: The Petitioner alleges that the following circumstances exist and requests that the New York State Public Employment Relations Board proceed under its proper authority. 1. Purpose of this Petition. (Check the line which is appropriate.) A. _____ B. _____ Applicability - the petition seeks a ruling as to the applicability of the Act. Scope of Negotiations - the petition seeks a ruling as to the scope of negotiations under the Act. 2. Petitioner a. Name (If employee organization, give full name, including affiliation and local name and number): b. Address (No. & Street, City, Zip Code, County): Telephone Number: c. Name, address and telephone number of the representative, if any, to whom correspondence is to be directed: 3. Identify any person(s), employee organization(s) or employer(s) whose interests are reasonably likely to be affected by this petition. Name Address American LegalNet, Inc. www.FormsWorkFlow.com 4. Is the subject matter of the petition the subject matter of any proceeding(s) or impasse currently pending before this Board or any other tribunal? YES NO If YES: Identify the tribunal, the nature of the proceeding, the date it was commenced, its present status and, if before this Board, its case number. 5. ISSUE a. Set forth a clear and concise statement of the issue. b. Set forth a full, clear and concise statement of the relevant facts, the grounds for and the petitioner's interest in obtaining a declaratory ruling, and the interests of the others listed in item "3" above as likely to be affected thereby. (Identify and attach all relevant documents.) 6. (OPTIONAL) Set forth a proposed declaratory ruling. STATE OF NEW YORK COUNTY OF ) SS.: ) _____________________________________, being duly sworn deposes and says, that (s)he is the petitioner above named, or its representative, and that (s)he has read the above petition consisting of this and _________ additional page(s), and is familiar with the facts alleged therein, which facts (s)he knows to be true, except as to those matters alleged on information and belief, which matters (s)he believes to be true. _______________________________________ (Signature) _______________________________________ (Title) Subscribed and sworn to before me this __________ day of _____________ PERB 562 (1/14) American LegalNet, Inc. www.FormsWorkFlow.com