Jorgenson, Nancy - Council at Large FORM 11(REVISED 1950)MILLER-DAVN6 Cp.,MINNEAPOLIS i
AFFIDAVIT OF CANDIDATE & RECEIPT FOR FILING
State of Minnesota
TOWN OR CITY ELECTIONS
ff No. Q
County of_�.oz S-
I, / 44&3ty \I -\Tv I?C' E /1)sv4)
(PrAt 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-
sota 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.
2
I am seeking election to the office
I reside in the city or township of
My post office address is: 3d
i� —(zip)
rignname as wanted on ballot)
Subscribed and sworn to before me this day of 192
'•/ ��� ,
Of-
Town) it y) Clerk tary Public
SEAL �� «t777 .-1 County, Minn.
NZINATION PETITION
We, the undersigned, registered voters of the City of Fridley,
hereby nominate c�6J�, , whose residence is
,V7.3 ���S�� or the office of
to be voted for at
the election to be held on the day of f y� , 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.
SnWM AND ICER
�- - ,� -
cr
, being duly sworn, deposes and says, "I
(Name of Circulator)
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:
J- S enSo�1
(Pl6ase Print)
(S' t Nominee)
r' and sworn to before me this sZo�day
of , 19
JAMES P. HILL
Nolnry PUbNC-MkWWSOta
nty
3-
(No ry lic) ►oarrr�. Exp.M01`a
My
This petition, if found insufficient by the City Clerk, shall be returned
to , at Number Street. j
I hereby indicate my willingness to accept the office of
if duly elected thereto.
(Signature of Nominee)
3/0/1/9
i
NOMINATION PETITION
We, the undersigned, registered voters of the City of Fridley,
hereby nominate , whose residence is
S or the office of
to be voted for at
the election to be held on the day o , 19 C!;
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.
S'PPM= AND NC�ER
s
1 AVE
• 6 �gn 5t,A'Aty., a)"d r,d/.�
s� It'e
being duly sworn, deposes and says, "I
(Name of Circulator)
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:
(Please Print)
(S' r f�hmineO
r' and sworn to before me this 20 m
— ay
JAMES P. HILL
IM�y ttibMoMNr�
(No lic) W oa�&W 3� "7
This petition, if found insufficient by the City Clerk, shall be returned
to , at Number Street.
I hereby indicate my willingness to accept the office of
if duly elected thereto.
(Signature of Naminee)
3/0/1/9 r
CITY OF FRIDLEY
PUBLIC DISCLOSURE STATEKW BY CITY OOUNCIL OR 001UNCIL
NAME
DATE X;:_
TO: CI 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.)
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,
off icer, director, trustee, partner, advisor or consultant.)
NAME OF BUSINESS FINANCIAL PERSCNAL
PARZiQE MIP EPC. ADMUM INTEREST INTEREST
(Use additional paper if necessary.)
2. A list of the norr-hcmestead real property located within the City of
Fridley in which I currently have a financial interest:
RF.FL PROPERTY ADDRESS
(Use additional paper if necessary.)
1
3. A list of the norr-hamestead real property located within the City of
Fridley in which I had a financial interest within the preceding three
(3) years:
NO[j--Br*ffnT D REAL PROPERTY ADUMS
01
(Use additional paper if necessary.)
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.)
NAMW OF BUSIMSS - OF ALL CDRPORATIONS
NAMES PA MMSHIPS, OR OMM BUSINESS WrMR;;aSES
(Use additional paper if necessary.)
I do swear (or affirm) that this report is a full and true statement
pursuant to Sec. 5.04 of the City Code.
Pi tune)
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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