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01-Bolkcom, Anne - Ward 3 OfFice of the Minnesota Secretary of State Filing# (�I AFFIDAVIT OF CANDIDACY Cash/Check#�_ Instructions Amount$ /D•!/� 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.204B.03) Candidate Informafion Name and Office / Candidate Name( it �I app on the ballot) � � (.� Office Sought District# For Partisan Office,Provide olitical 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 cou ty sh iff office cand' ates. � Street Address � � City � State�Zip Code � ❑ My residence address is to be classifie s 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 Con[act �/Q �� � � ' ���� Candidate Phone Number(Required) ( � v Campaign Contact A dress(Requ'red for thos who ave checked the box above): Street Address t City � State�L�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 community. If filing for a state or local office,I also swear(or a'ff'irm)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.2046.06,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 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 filingjointly 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 ot 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 Memb I have not been convicted of an offense for which registration is required under Minn.Stat.243.166. • County,Municipal, cho District,or 5 cial Dist id OH'ice—I meet any other qualifications for that office prescribed by law. Candi e Signature � Date� � Su ib d and sworn o f^e me this�day of ,20.�. A08ERTA S.COLUNS otary public other o cer empowered to take and certify acknowledgement �C��9SMa 1My .le�91,2015 White Copy—Filing Officer Vellow Copy—CFPD Board Pink Copy—Public Information Goldenrod Copy— . COUNTY OF ANOx:.A OFFICE OF ELECTIONS 8L VOTER REGISTRATION �On��rrv 325 EAST MAIN STREET•ANOKA,MINNESOTA 55303 COt�l� j 1 PxorrE: (763)323-5275 F�: (763)422-7526 2014 AutoMARK Pronunciation Form In 2006, a second voting system was adopted which is specrfically 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 � � � �Q L Candidate: �C O�Y1 Phonetic �L � �,4Yv�Q.- Spelling:_ � . Office sought: ����,� Date: v �j �� City of Fridley Nomination Petition We,the undersigned,re 'stered voters of the Ci of Fridley,hereby nominate 1J dJV�.- ��Ml whose residence is 2� � for the office of � e vote for at the election to be held on the th da f 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 Year: Printed Full Name an Signatur Address S�� �- �-.i`�.,11��� 2 � .�'JU,� . . a'�..D-�3� 5� � ` 1��� ! ��` �� � l� C�j' �G��L /v Cr7�CJ / T✓�C/�U,�� cSJ NC --� � �' � L� /-e 2n�9� �u,%/,n� � �O/ --d�1 C�b��`" rl�� Gl'3 `� ,M a rth c�.. 1�ec Kd d h 1 `"7Y��3 � ... G�/�c:.i N G l�/�7 �- ;� i' ,(�� � ��� �' � o �- 5 7 h � L L,�;r � �v ) '►�� �v D � �� �� � � �� c� - �, l�� ���� ��� � �•^ � � . � q:�� / � � `'l/oZ.., " , �9 S'� CA�o�.�l� ac �K �r�7�/'1 ,�p�-ICL+c� W1 , 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 n�to appear oa,the ball`t exactly as� follows: t1 I' _��< <C !r✓1 (Please Print Name) This petition,if found insuffic' n by the City Clerk,shall be returned to � at � ` � ,Fridley,Minnesota. I hereby' icate y willin ess to accept the office of Counc�l ember War�if duly elected thereto. (Signature of Nominee) S cribed and swo efore me this�d of 1 0 4. _ Y � pvotary Pub ' • ROBE��OWNS ��,�on��p,,,�a SSy�'�--- , �.�. ��`c��1 '�.�a..�:� �� ���� �YI�' � ' " ' t ,� f q��� i � �� , �� ����-�.� � ��� �,� ��.���i g3�3�: �G� � � �,� Lvc�C L�- J U"��S � � 5� � � ..*. . City of Fridley Public Disclosure Statement By City Council Members or City Council Candidates Name: � � Date �Ti C� l Position Title: 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 a11 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 sha11 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) 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 Rea1 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 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 Corporations, 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 urs ant to Section 5.04 of the Fridley City Code. ���� (Signature) Note: This statement must be filed annually or when there is a material change in financial interest or in position held.