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Varichak, Dolores - Ward 2 Office of the Minnesota Filing# a Cash/Check# 7g�-/ Secretary of State Amount$ 10.;.74V 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 party candidate,you must file both an affidavit of candidacy and a nominating petition. (Ms.204B.03). —�' Please print or e. Name(as it will appear on the ballot): �c�LOCL j /n Office Sought: q (*%,N nC;I o.T b�;— District#: For Partisan Office Provide Political Party or Principle: For Judicial Office Provide Name of Incumbent: Note:All address and contact information is optional for judicial,county attorney and county sheriff office candidates. Candidate Residence Address(Do not complete if residence address is to be private and checkbox below is marked) Street Address: I S.5 8 1 8R-n- A LF 22,0,an Air City: EW A z:�e Stater_Zip: Ss'y,l ci -- ❑ 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. Candidate Phone Number(Required): ) Campaign Contact Address(Required for those who have checked the box above) Street Address: City. State: Zip: Website: Email Cl— Yd R(0--,o-k— Q a e4—o, La 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 Mjnnesota.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 Minnesota Statutes,section 243.166. • C nty,Municipal,School District,or Special District Office-I meet any other qualifications for that office prescribed by law. ' S,�{ sdbed and sworn before me this Candidate Signature d day of '2 o i O _ lel l 0CYNTHIA J.RUSCHY Not public or other officer empo red to Notary Public-Minna ota Date MycomO'WW,SIMIN2012 take and certify acknowledgments. white copy—Filing Officer yellow copy—CFPD BoardRev.5-10 goldenrod copy—Candidate pink copy—Public Information t'• 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: ILn o S Vl,�, c�r sc Age: _ Your address: J S ,' L�2��-:�� Q &IJ Telephone Number: -) CQ3 -S E-Mail: —y6a` Web site: f Occupation and employer: ADD 2a,+6 G2r)U���nc CI hc, �.�CzkwS / o 47 e- Office Sought: C)t,n 0 ➢^ �� (�,u'� Political party or principle: Current office held: ����_ �- si cn�_ First year elected or appointed: Previous elected or appointed public offices: R-k a- L<_ Endorsements: Comments or filing statement(use this space only): I c fy that the info mation provided on this form is true. I Candidate Signature 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 Office Building, 100 Rev Dr Martin Luther King Jr.Blvd,St.Paul,MN 55155 COUNTY OF ANO KA ,-� OFFICE OF ELECTIONS & VOTER REGISTRATION COUNTANO 325 EAST MAIN STREET•ANOKA,MINNESOTA 55303 Y PHONE: (763)323-5275 FAX: (763)422-7526 2010 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. I i Name of Candidate: locws Phonetic � Lo 2t 5 VCa i c�J< Spelling: Office ��yy sought: Date: AW ri City of Fridley Nomination Petition MYOF FRUX" - m We,the undersigned,registered voters of the City of Fridley,hereby nominate VP c448 1C. whose residence isISjjoa d ZL� for the office of Councilmember Ward�, to be voted for at the election to be held on the 2° dayf November 2010, 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 Name and Signature Address Year: �V/�$' -c= If FZ+b1�Y ,�1IV f+ I`�- - 4j Pr c ctr�e� a A A Pe Mk 4q5 r vpDv po Mry 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 o the ballot exactly as follows: JAIZ i U-a 8 K (Please Print Name) This petition, if found insufficient by the City Clerk, shall be returned to 1 Y ACU c_r- at _-t7 ,Fridley,Minnesota. I hereby ' dicate my willingness to accept ffi the oce of Councilmember Ward Lj if duly elected thereto. ---Lm i (Signature of Nominee) Subscribed and sworn to before me this'�•7 day of ,2010. CYNTHIA J.RUSCHY n Nota Public-Minnesota My com elon (No Public) vireeJa�,s+.z°iz ri ppi� City of Fridley Nomination Petition PRU We,the undersigned,registered voters of the City of Fridley,hereby nominate VAQj L F1 A R whose residence is f SS'13 X14 �J.t` for the office of Councilmember Ward , to be voted for at the election to be held on the 2°d day of November 2010, 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 Name and Signature Address Year: e ft r� r vim, '�<-k11� k— I r1 ict �© non J'1 4 fGW S4 ASC. 5'5 q 3a 1i Ct n 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 wiy name to appear on the allot exactly as follows: L)Lo(LE3 M - �rjq?-1 ,L l-i (Please Print Name) This petition if found insufficient by the City Clerk,shall be returned to —byLf-),LGS M - VAR4 (.-AAk, at 'l rArL�Ni( [, �JE„Fridley,Minnesota. I hereb dicate my willingness to accept the office of Councilmember Ward_if duly elected thereto. (Signature of Nominee) Subscribed and sworn to before me this day of IT)-.- '2010. (Not Public) CYNTHIA J. RUSCHY ' Notary Pubiic-Minnesota ;,;F.+ My Commission Expires Jan 37,2012 3. City of Fridley Public Disclosure Statement By City Council Members or City Council Candidates Name: Date S a /1 b Position Title: OjnC4nCj rvvo L D SQ 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 Partnership,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 I ^` n (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 (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 n (Use additional paper if necessary) i I do swear (or affirm)that this report is a full and true statement pursuant to Section 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. i I n