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Kirkham, Jack - Mayor FORM 11(REVISED 1980)MILER-OAVIS`O.,MINNEAPOLIS AFFIDAVIT OF CANDIDATE & RECEIPT FOR FILING TOWN OR CITY ELECTIONS Stat�M Minnesota A lvo.�_ County of— I, K J� / (RIcN )901 (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 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. I am seeking election to the office of I reside in the city or township of -C My post office address is- '�►� v" G -moi. � J r (Zip) / C ( ign name as wanted on ballot)) Subscribed and sw, �eore, t +s°�f '" da of G 9 t9 y , 19— SIC- MI ; 1LSOTA S Ccul�i'.21986 (Tofyn ,(City) Clerk—N taryPublic SEAL , ^� i. Ex,ire�P+lay , Q��_��— County, Minn. NOMINATION PETITION R We, the undersigned, electors of the City of Fridley, hereby nominate JA C K ©, C� I K ' < 4 A P1 whose res i dence i s `l3 � ' � 7 4,ve for the office of —Ma y a r to be voted for at the election to be held on the day of 9 ty-e�. , 19D; and we individually certify that we are qualified electors and that we have not signed more nomination petitions of candidates for this office than there are persons to be elected thereto. Name Street and Number n J being duly sworn, deposes and says that s/he Name of Nominee is the circulator of the foregoing petition paper containing signatures, and that the signatures appended thereto were made in his/her 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: A C- K K )RKHAM Please Print Signature of Nominee Subscr'bedand worn to before me this �D. day of • 19 3 XAAAAAA&AMAMAA& V"A&&n.vnnAAAMA', 5 ... ', SHIRLEY A. HAAPALA / NOTARY PUBLIC- MINNESOTA tA.NCKA CCUN I'i ` t ( i•9yCon�issionExpires May 28,IONS Notary Publ i vvvvvvvw wwwv■ This petition, if found insufficient by the City Clerk, shall be returned to at Number elJo— c/, ? Street. I hereby indicate my willingness to accept the office of c�611/ ErI��� _ if duly elected thereto. Signature of Nominee) CC1280 I NOMINATION PETITION We, the undersigned, electors of the City of Fridley, hereby nominate JAC K �. kt K K R A M whose residence is —-'15o ^ d/ 7,4ee for the office of �4 a V or to be voted for at the election to be held on the �-� day of 19�a; and we individually certify that we are qualified electors and that we have not signed more nomination petitions of candidates for this office than there are persons to be elected thereto. Name Street and Number / 4 5P 4C ,4- ,4 f Ale- being duly sworn, deposes and says that s/he (Name of Nominee is the circulator of the foregoing petition paper containing signatures, and that the signatures appended thereto were made in his/her presence and are the genuine signatures of the persons whose names they purport to be. I wish my name to JAC- appear on the ballot exactly as follows: K PA hA (Please Printf Signature ofNominee) Subs cr'bed and s o to before me this 1� day of 19 . ,I nn,vAnnnnAAnnnnnnnnv'-VAv-^s,nnnnnn.- SHIRLEY A. HAAPALA NOTARY PUBLIC- MINNESOTA ^,N :'..A CGUN f'.' C My commission Expires May 26,1926 tary Public vv\,-,Nvvv v,"I This petition, if found insufficient by the City Clerk, shall be returned to J�C k (� K(r k4,,,k at Number L/30 - 4/, 7 Street. I hereby indicate my willingness to accept the office of �df,�o r if duly elected thereto. 1 Signature of Nominee) CC1280 CITY OF FRIDLEY j PUBLIC DISCLOSURE STATEMENT BY CITY COUNCIL OR COUNCIL CANDIDATES NAME ac K (/ r K//d�- �- l o- g3 DATE TO: CITY CLERK In conformance with Section 30 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 30, 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 30, 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 on consultant. ) NAME OF BUSINESS, FINANCIAL PERSONAL PARTNERSHIPS, ETC. ADDRESS INTEREST INTEREST (Use additional paper if necessary.) -2- 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 fJ (Use additional paper if necessary. ) -2- -3- 3. A list of the non-homestead real property located within the City of Fridley in which I had. a financial interest within the preceding three years. NON-HOMESTEAD REAL PROPERTY ADDRESS Q I (Use additional paper if necessary. ) -3- -4- 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. ) NATURE OF BUSINESS - OF ALL CORPORATIONS NAMES PARTNERSHIPS, OR OTHER BUSINESS ENTERPRISES I (Use additional paper if necessary . ) I do swear (or affirm) that this report ✓� ��1 G / is a full and true statement pursuant to Section 30 of the City Code. Signature Note: This statement must be filed annua ly or when there is a material change in financial interest, or in position held. -4-