03-Saefke, Jim - Ward 1 .� ��� . Office of the Minnesota Secretary of State Filing# G/ -ta3
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- AFFIDAVIT OF CANDIDACY as heck#
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Instructions
All information on this form is available to the public.Information provided will be published on the Secretarv of State's website.If filing for
partisan office and not a major party candidate,you must file both an affidavit of candidacy and a nominating petition.(Minn.Stat.2048.03)
Candidate Information
Name and Off'ice
Candidate Name(as it will appear on the ballot) � �/!����C���`C(�
Office Sought �J �(L l� .Z �`�O (PrL��/ L i21(��'YL�(%/•�-- District#
For Partisan Office,Provide Political Party or Principle
For Judicial Office,Provide Name of Incumbent
Residence Address
Do not complete if residence address is to be private and checkbox below is marked.All address and contact information is optional for federal,
judicial,county attorney,and county she iff office candidates.
Sr '��
Street Address ' f
City �(�� D.�c; State Zip Code � � �:3 Z-/
❑ My residence address is to be classified as private data.I certify a police report has been submitted,or I have an order for protection
regarding my safety or my family's safety,and I have attached a separate form listing my residence address.
Campaign Address and Contact l �/
Candidate Phone Number(Required) � �3/ � � ( � 7�� �
Campaign Contact Address(Required for those who have checked the box above):
Street Address
City State Zip Code
Website Email
Affirmation
For all oH'ices,I swear(or affirm)that this is my true name or the name by which I am generally known in the commu�ity.
If filing for a state or local office,I also swear(or affirm)that:
• I am eligible to vote in Minnesota;
• I have not filed for the same or any other office at the upcoming primary or general election (except as provided in M.S.204B.06,subd.1(2));
• I am,or will be on assuming office,21 years of age or more;
• I will have maintained residence in this district for at least 30 days before the general election;and
• If a major political party candidate,I either participated in the party's most recent precinct caucuses or intend to vote for a majority of that
party's candidates at the next general election.
If filing for one of the following offices,I also swear(or aff'irm)that I meet the requirements listed below:
• United States Senator-I will be an inhabitant of this state when elected and I will be at least 30 years old and a citizen of the United States for
not less than nine years on the next January 3rd,or if filled at special election,within 21 days after the election.
• United States Representative-I will be an inhabitant of this state when elected and I wili be at least 25 years old and a citizen of the United
States for not less than seven years on the next January 3rd,or if filled at special election,within 21 days after the election.
• Governor or Lieutenant Governor-I will be at least 25 years old on the first Monday of the next January and a resident of Minnesota for not
less than one year on election day.I am filing jointly with
• Supreme Court Justice,Court of Appeals Judge,District Court Judge,or County Attorney-I am learned in the law and licensed to practice law
in Minnesota.My Minnesota attorney license number is and a copy of my license is attached.
• State Senator or State Representative-I will be a resident of Minnesota not less than one year and of this district for six months on the day of
the general or special election.
• County Sheriff-I am a licensed peace officer in Minnesota.My Board of Peace Officer Standards and Training license number is
and a copy of my license is attached.
• School Board Member-I have not been convicted of an offense for which registration is required under Minn.Stat.243.166.
• County,Municipal,Sc I Distrid,or Special District Office-I meet any other qualifications for that office prescribed by law.
Candidate Signature � Date Z- Z-�'/`f
Subscribed and sw be re e this�day of . �� ,ZD �,;, A,SKOGEN
� �� DEBNA
NOTARY PUBLIC-1JNNNES07A
�� 31.2015
Notary public or other officer empowered to take and certify acknowledgement NIyGm'�I�i6��
.,�,..
White Copy—Filing Officer Yellow Copy—CFPD Board Pink Copy—Public Information Goldenro — andidate Rev.12/2013
MINNESOTA SECRETARY OF STATE
ELECTION CANDIDATE INFORMATION FORM
(VOLUNTARY DISCLOSURE)
Please type or print clearly
You are invited to complete this form and leave it with the filing office for public information. The Secretary of
State does not edit the information submitted. Information submitted by state and federal candidates will be
scanned and placed on the Secretary of State's web site:www.sos.state.mn.us. If you are filing for state or federal
office at a county,please FAX a copy of this complete form to us at 651-296-9073 if you wish this information to
be published on the web.
Your Name: � t �'YI �4 i9�= r K(= Age: �iP`�
Your address: �O� �3 � ^ �S^`-�' S % � •� �P?/D.��—`� IyI rt) S^5�J�Z-
Telephone Number:(����3 �7 - C� '
E-Mail: Web site:
Occupation and employer: ���T��Q �/)
Office Sought: �,c.�y9/Ly 1_ �'a�i r�Q / � _rYj�[=i�
Political party or principle:
Current office held:�'/9�y � �v�������C��� First year elected or appointed: �ZGL7(D
Previous elected or appointed public offices:
Endorsements:
Comments or filing statement(use this space only):
I cert' that the information provided on this form is true.
� � �/y/ .�o/�
Candidate Sign r Date
If you have any questions,please contact the Elections Division at 651-215-1440.
Please submit this information: Fax: 651-296-9073
Mail: 180 State Of�ice Building, 100 Rev Dr Martin Luther King Jr.Blvd,St.Paul,MN 55155
COUNTY OF ANOK:A
OFFICE OF ELECTIONS & VOTER REGISTRATION
AN�KA 325 EAST MA�S�E'r•Alvo�,MINNESOTA 55303
C�t�l� j j PxoNE: (763)323-5275 F�: (763)422-7526
2014 AutoMARK Pronunciation Form
In 2006, a second voting system was adopted which is specifically designed to assist
voters with physical disabilities—the AutoMARK. The AutoMARK is a ballot marking
device that individuals with physical disabilities may use to vote privately and
independently. One of the unique characteristics of the AutoMARK is that it is
programmed to speak each candidate's name. As a result, we are asking candidates to
provide a phonetic spelling to ensure that the AutoMARK pronounces each candidate's
name correctly.
Name of
Candidate: T� ✓r'j � /�E�K c.=
Phonetic
Spelling: �1 / ✓�'1' �S r4 rC /t C� �
Office
Sougnt: c�-� ��v � �u�e�,��c C--�r3c;/�—
Date: <P �-��/�
�� City of Fridley Nomination Petition
We,the undersigned,registered voters of the City of Fridley,hereby nominate_��►�'l S/.��=�/�[C.-
whose residence is fo� ,'� ( -s' t� S f tJ�� � , for the office of;J��J l �eJe r� ,to be voted
for at the election to be held on the 4th day of November 2014, and we individually certify that we are
registered voters and that we have not signed more nomination petirions of candidates for this office than
there are persons to be elected thereto.
Birth
Year: Printed Full Name and Signature Address
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, being duly sworn�and says, «I am the circulator of the foregoing
petition paper containing signatures and that the signatures appended thereto were made in my presence
and are the genuine signatures of the persons whose names they purport to be."
I wish my name to appear on the ballot exactly as follows:
T� �'Yl ���L=�Kc:
(Please Print Name)
This pefition,if found insufficient by the City Clerk,shall be returned to T�� ,S�t�F(tN=
at (o /3/ "S'�'''.ST � E � ,Fridley,Minnesota. I hereby indicate my willingness to accept
the office of Councilmember Ward/if duly elected thereto. t
(� (Signatur of Nominee)
��
Subscribe and sw t before me this�day of ,2014.
�
(Notary Public) DEBRA A.�KQGEN
1�� NOTARYPUBLI -FARdIVESOTA
My Cortrtrdssion F�ires Jan.31,2015
�
�
City of Fridley Nomination Petition
��
We,the undersigned,registered oters of the City of Fridley,hereby nominate �)✓Y(. �S�9(%a(<�
� l � ��iL
whose residence is ���l r � ' S T 1�'-� , for the office of Wf�D1 �ol��/L�tl�to�ie voted
for at the election to be held on the 4th day of November 2014, and we individually certify that we are
registered voters and that we have not signed more nomination petitions of candidates for this office than
there are persons to be elected thereto.
Birth Printed Full Name and Signature Address
Years { , �
j�i S ���c� � �.7� S ��i �
(�j � .'�� r-- � }_ 4e%C N �r
�G � T �:�� �
�� ,�y� �,q`c �r(� , being duly sworn, deposes and says, "I am the circulator of the foregoing
petition paper containing signatures and that the signatures appended thereto were made in my presence
and are the genuine signatures of the persons whose names they purport to be."
I wish my name to appear on the ballot exactly as follows:
�i/�°1') �S/g c:,ri�-t v'
(Please Print Name)
This petition,if found insufficient by the City Clerk,shall be returned to,��M sfl��k��
at r/3/ -S'# S%/�.� ,Fridley,Minnesota. I hereby ' dicate my willingness to ccept
the office of Councilmember Ward 1.if duly elected thereto. ^ �
�,Y,,c� C �C�.�
(Signatur f Nominee)
�c�
Subscribed and sworn to fore me this�day of ,2014.
,
(Notary Public) ,�,,,+,s�,�
'i�' DEBRA A.SKOCEN
NOTARYPUBUC-MINNESOTA
My Comcr�ssian Expires Jan.31,2015
City of Fridley
Public Disclosure Statement
By City Council Members or City Council Candidates
Name: J l ✓� cs At�K� Date C��Z�.ZO/�
Position Title: u> ��17 ,� �.D C1/t�F�.� �'I2 G/YI,�E/�
In conformance with Section 5.04 of the Fridley City Code,I hereby make the following
declarations regarding my financial and personal interests:
1. Names of all business corporations,partnerships, other business enterprises, or governmental
agencies doing business with the City of Fridley or located within the City of Fridley.
a) With which I have a financial interest.
(As used in Chapter 5,the term fmancial interest shall be deemed to include ownership of
more than 10%of: the outstanding stock in a corporation, an interest in a partnership,
proprietorship, or other business entity, or an interest in real property. Financial interest
shall apply to real or personal properties owned by one person making the disclosure and
by said person's spouse.)
b) With which I have a personal interest.
(As used in Chapter 5,the term personal interest shall be deemed to apply whenever a
person required to make a disclosure under this code of ethics sha11 be associated with a
business as an employee,offcer,director,trustee,partner,advisor or consultant.)
Name of Business, Address Financial Personal Interest
Partnershi , Etc. Interest
O C
(use additional paper if necessary)
2. A list of the non-homestead real property located within the City of Fridley in which I
currently have a financial interest:
Non-Homes#ead Reai Property Address
n�c��' �
(use additional paper if necessary)
City of Fridley Public Disclosure Form Page 2
3. A list of the non-homestead real property located within the City of Fridley in which I have
had a financial interest within the proceeding three years.
Non-Homestead Real Property Address
►�8��•'C
(use additional paper if necessary)
4. A list of names and nature of business of all corporations, partnerships, or other business
enterprises with which I have a financial interest and in which I know one or more other
persons covered by this code of ethics also having a fmancial interest in said enterprise.
(This list shall indicate the name or names of such persons or persons having such interest in
said enterprise.)
Nature of Business—of All Corporarions,
Names Partnershi s,or Other Business Ente rises
. �
(Use additional paper if necessary)
I do swear(or affirm)that this report is a full and true statement pursuant to Secrion 5.04 of the
Fridley City Code.
�-
ignature)
Note: This statement must be filed annually or when there is a material change in financial
interest or in position held.