Bolkcom, Ann - Ward 3 FORM(REVISED 1980)MILLER-DAVIS CO.,ST.PAUL,MN
AFFIDAVIT OF CANDIDATE & RECEIPT FOR FILING
State of Minnesota TOWN OR CITY ELECTIONS
County of [- I ' SS. No. l
(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 Minn_
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
least 30 days by election day. I have not filed for any other office at this election. at
I am seeking election to the office of `
I reside in the City or Township of
My post office dress is
(Zip)
Subscribed and sworn to before me this (Sign name as wanted on ballot). ��
day of
S1@
=fON SMF M�
(1wn) cty)CI rk� ar Pu
JANUARY 31.2006 County,Minn.
W
City of Fridley Nomination Petition
CTIYOF
F OF
We,the undersigned,registered voters of the City of Fridley,hereby nom' ate
whose residence is for the office of 1144 ,to be
voted for at the election to be held on t Jr day of 02; and we individually
certify that we are registered voters and that we have not s' ed more nomination petitions of candidates
for this office than there are persons to be elected the to.
Date. Prilat,o ,ame d Signa Address _L
7 0� + cjz-"cuff LG
? Go2 (a JOD
Nil�
�~ U7 Vo
�.�
Lfbein g dulyiArn, eposes and says, "I am the circulator Jt1he 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 by name appe the ballot exactly as follows:
(Please Print Name)
This petition,if found insufficient
by the City Clerk, shall be returned to ��am at
IJV ,Fridley,Minnesota. I hereby indicate my willingness to accept the
office of if duly elected thereto.
(Signature of Nominee)
S cribed ands fore me thisq;�—ljday of ,2002.
ROBERTA S.WWN,S
J! NOVX sic- a
(Notary P ic) WOOMMISSION EXPIRES
JANUARY 31,20M
AW
City of Fridley Nomination Petition
G1YOF
FRIDR
We,the undersigned,registered voters of the Cit71for
ofidley,hereby nominate
whose residence is the office of6 1 E to be
voted for at the election to be held on t e day of U 2002; 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. II
Date Printed Name and Signature. AddresisF
�� Da �h�nen �u�, ,�c�,-n r0�'1�71�i' •�•�/E r�i�l 55"�3�.Z.
A] Lj!��.kYY% ,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 by name to appear on the ballot exactly as follows:
ollows:
(Please Print Name)
his petition,if foun ins'u1f i . nt by the City Clerk, shall be returned to I mat
10 S)j rjt 'V ,Fridley,Minnesota. I hereby indic y willingness to accept the
office of (,t if duly elected thereto.
K,8
a&,
(Signature of Nominee)
S cribed and swo b o me thio` day of 12002.
(Notary Publ
ROBERTA S.COUM
NOXW ROX-4MMM
W'COMMISSION EFS
JANUARY 31,2005
City of Fridley
Public Disclosure Statement
By City Council Members or City Council Candidates
Name: (_ Date
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 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.)
Natne.ofBusiness, AAddro"' Financial Int resx: P san l inter
Partners�i ;Etc.
(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:
N&Romest d Rot j? o 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 years.
Ton= iad 11'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.)
Natuf mess df X11 Ctpoions,
Nam ,. Pi s,or, psins nsx.
(Use additional paper if necessary)
I do swear(or affirm)that this report is a full and true statement pursu 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.