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Affidavit of Candidacy
All information on this form is available to the public.Information provided will appear on the Secretary of State's website at
www.sos.state.mn.us.
Note:If filing for partisan office and not a major parry candidate,you must file both an affidavit of candidacy and a nominating petition:"Candidates
for any partisan office who do not seek the nomination of a major political party shall be nominated by nominating petition as provided in sections
20413.07 and 20413.08,and. . .shall file an affidavit of candidacy as provided in section 204B.06."(Minn. Stat. section 204B.03).
Please print or type.
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it will appear on the ballot): l'3 � - District#:
ught:san Office Provide Political Party or rinciple:
For Judicial Office Provide Name of Incumbent:
Legal Residence Address
Street Address:
City: . ..L C-
State: 4ihL Zip:
Campaign Contact formation
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Street Address:
City: State: ��Zip: 5.S
Website: / Email:
Phone Number: O
For all offices,I swear(or affirm)that this is my true name or the name by which I am generally known in the community.
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;
• 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 affirm)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 will 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
• 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
• School B ler-I have not been convicted of an offense for which registration is required under Minnesota Statutes,section 243.166.
Coun Municipa School District,or Special District Office-I meet any other qualifications for that office prescribed by law.
Subscribed and sworn before me this
Candidate Signature f
DEBRA A.SKOGEN
/ bMC �Eores lansi2pto Nota public or other fficer emp ered to
Date
(Notary stamp) take and certify acknowledgments.
Rev.4-06
white copy—Filing Officer yellow copy—CFPD Board goldenrod copy—Candidate pink copy—Public Information
ri City of Fridley Nomination Petition
CTIYOF
FR[DLFY
We,the undersigned,registered voters of the City of Fridley,hereby nominate
hose residence is�rc S� 1?1 V-Mt11C-Hr ;,/2 , for the office of
to be voted for at the election to be held on the 7 day of
2006; 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: Printed Name and Signature Address ^ f/ J�
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,( '"being duly sworn, deposes and says, "I am the circulator of the foregoing
petition paper containing s atures 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 by name to appear on the ballot exactly as follows:
(Please Print Na pd)
This petition, if found insufficient by the City Clerk, shall be returned to
at , Fridley, Minnesota. I
hereby indicate my willingness to accept the office of if duly
elected thereto.
( ignature of minee)
Subscr' and swo to efore me thisday of , 2006.
(Nota ublic)
DEBRA A.SKOGEN
Notary Pdwo-Minnesota
MY C—Nsdw ElVkm Jan 91,2010
y
AWW
City of Fridley Nomination Petition
CIIYOF
FRIDL EY /71
We,the undersigned,registered voters of the City of Fridley,hereby nominate 12
.�
whose residence for the office of
to be voted for at the election to be held on the 7_ day of
1V6 V , 2006; 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 elec d t reto. 0/
\
Date- P am andinature Address
3
1 ._.,moi +a
'/ t )YG J-V 1,51J
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 wis by name to a pear on the ballot exactly as follows:
Please Print Na e)
This petition, if found insufficient by the City Clerk, shall be returned to
at , Fridley, Minnesota. I
hereby indicate my willingness to accept the office of if duly
elected thereto.
(Signature of No ee)
Subscri d sworn to foe�me this day of , 2006.
(Nota Public)
DEBRA A SKOGEN
Notary P mhnesom
My Gammon E*res Jan 31,2010
` City of Fridley
Public Disclosure Statement
By City Council Members or City Council Candidates
Name: /! Date
Position Title: r
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 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 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 shall be associated with a
business as an employee, officer, director,trustee,partner, advisor or consultant.)
Name of Business, Address Financial Personal Interest
Partnershi , Etc. Interest
(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)
n
h
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
(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 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
(Use additional paper if necessary)
I do swear(or affirm) that this report is a full and true statement pursuant to Section 5.04 of the
Fridley City Code.
c'
(Si ure)
Note: This statement must be filed annually or when there is a material change in
financial interest or in position held.