Bolkcom, Ann - Ward 3 FORM(REVISED 1980)MILLER-DAVIS CO.,ST.PAUL,MN
AFFIDAVIT OF CANDIDATE &RECEIPT FOR FILING
TOWN OR CITY ELECTIONS
State of Minnesota No. 3
County of 1) itss.
I, �?h �bLKCC7YYl
(Print name as wanted on ballot)
swear (or affirm) that I am qualified under the Constitution and Laws of the United States and State of Minne-
sots to seek the elective public office indicated below. I am a qualified voter in the subdivision where I seek
election. I will be 21 years of age or more on assuming office. I will be a resident of my election district for at
least 30 days by election day. I have not filed for any other office at this election.
3
I am seeking election to the office of C4 'Ott
I reside in the City or Township of
My post office es i
(Sign nam as wanted on ballot)
Subscribed and sworn to before me this day of , 19
ROBERTA S.COLLSO
4 NOTARY PUBLIC-MW*$CTAT ), Ci Clerk N ry Public
ANOKA COUNTY
My Comm.Exp.Jan.91,2000 ounty,Minn.
NOMINATION PETITION
We, the undersigned, registered voters of the City of Fridley,
hearby nominate L ((2W\ , whose residence is
, for the office of
6U, by) to be voted for at
the election to be held on the i� day of Abi19
� �S
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.
DATE STREET AND ADDRESS
ok
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C I I?
,• �III`�-� Y Y YLa
7
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OICOK
_. being duly sworn, deposes and says, "I am
(Name of Circulator
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. 11
I wish my name to appear on the ballot exactly as follows:
Please Print)
L
Signature of Nominee)
Sub c ibed and sworn to before this day
of y 1 , 19�` __
W
T !
` S.CCOLLINS
� NNor �PoT�(Notar Public ANo�
J
This petition, if found insufficient by the City Clerk, shall be returned
to , at Number Street.
I hearby indicate my willingness to accept the office of
if duly elected thereto.
(Signature of Nominee)
6/94
NOMINATION PETITION
We, the undersigned, registered voters of the City of Fridley,
hearby nominate , whose residence. is
tp2kLloc _3��02 -1
for the office of
to be voted for at
the election to be held on the __3 day of �(11) 19
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.
DATESTREET AND ADDRESS
K M�R Z� S4-&F�
(Name of Circulator) 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 app ar on the ballot exactly as follows:
(Please Print)
i
gnature of Nominee)
OSu f
ibed and sworn to before�}W this day
—�, 19 �_.
nODERTA S.COLL=
' - -- R NOTARY PUBLIC-MINNESOU
1� ANOKA COUNTY
(Notary u 1 i c) �.�.� My Comm,Exp.Jan.91.2000
This petition, if found insufficient by the City Clerk, shall be returned
to , at Number Street.
I hearby indicate my willingness to accept the office of
_ if duly elected thereto.
(Signature of Nominee)
6/94
CITY OF FRIDLEY
PUBLIC DISCLOSURE TATEMENT BY CITY COUNCIL OR COUNCIL MATES
NAMES? O t. GL DATE
TO: CITY CLERK
In conformance. with Sec. 5.04 of the 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 financial 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 the person
making the disclosure and by said person's spouse.)
i
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 shall be associated with a business as an employee,
officer, 'director, trustee, partner, advisor or consultant. )
NAME OF BUSINESS FINANCIAL PERSONAL
PARTNERSHIP, ETC. ADDRESS INTEREST INTEREST
i
(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-HOMESTEAD REAL PROPERTY ADDRESS
(Use additional paper if necessary.)
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(3)years:
NON-HOMESTEAD REAL PROPERTY ADDRESS
/Z
4. A list of the 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 financial 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 CORPORATIONS
NAMES PARTNERSHIPS, OR OTHER BUSINESS ENTERPRISES
I
{
(Use additional paper if necessary.)
I do swear (or affirm) that this report is full and true statement
pursuant to Sec. 5.04 of the City Code.
(Sign ure)
Note: This statement must be filed annually or when there is a
material change in financial interest or in position held.
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