Maeckelbergh, Gerald North Suburban Hospital District Office of the Minnesota Secretary of State Filing#
AFFIDAVIT OF CANDIDACY Cash/Check#�
Amount$
Instructions
All information on this form is available to the public.Information provided will be published on the Secretary 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 Information
Name and Office
Candidate Name(as it will appear on the ballot) �'""�`"J K- ►r` G�il��-��C�. (�
Office Sought O r-Ou y MvC District#
For Partisan Office,Provide Political 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 county sheriff office candidates.
Street Address 4 �)C;; C,fZC-GK $L-d-v)
City 0` State MA) Zip Code J5tys-L
❑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 for my
(or my family's)safety,or my address is otherwise private by Minnesota law.�1
I have attached a separate form listing my residence address.
Campaign Address and Contact ,f'�-p—(ec �Q-- -- �e / 19 �'I� 32-
Candidate Phone Number(Required) 7�✓ ✓ l� I"J��
Campaign Contact Address(Required for those who have checked the box above):
Street Address
City State Zip Code
Website Email
Affirmation
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(except as provided in M.S.204B.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 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 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 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 Minn.Stat.243.166.
• County,Municipal,School District,or Special District Office-I meet any other qualifications for that office prescribed by law.
Candidate Signature / " Date 7/3L (Q
/�� /��
Subscribed and rn to bef a is—JLLay of LJ,k+F�4 uN� ^��nnnrmnn�
s DEBRA A.SKOGEN
Notary public or other office empowered to take and certify acknowledgement Notary PubfiFlf1€361�
Commission EVfts
White Copy—Filing Officer Yellow Copy—CFPD Board Pink Copy—Public Informotion Go rFot�Co vA4�k� t
Office of the Minnesota Secretary of State
ELECTION CANDIDATE INFORMATION FORM (VOLUNTARY DISCLOSURE)
Instructions
Federal and State candidates are invited to complete this form in whole or in part.Submit it through the filing officer
or by sending it to the Secretary of State via email (elections.de pt@state.mn.us)or mail:
180 State Office Building, 100 Rev. Dr. Martin Luther King,Jr. Blvd.,St. Paul,MN 55155-1299
Information submitted on this form will be published on the Secretary of State's web site.The Office of the
Secretary of State does not edit the information submitted.Additional sheets will not be published.
Candidate Information
Candidate Name &P-At.0 R, Ydt(�EeK{c,��s2��y
Office Sought � U -� �!' C, -Pt5Tg4C'
Political Party or Principle
Address qz6-
Preferred mailing address(if different)
Telephone 4.3 5'74(,l't-)�9b Fax
E-Mail Web site- -'
Occupation and Employer ' t j o: {b) �T�C�}'t�l� Age
Current Office Held /vUl SX J4'ZIYJ - 1S'(, First Year Elected or Appointed l l g
Previous Elected or Appointed Public Offices
Endorsements
Comments or Filing Statement(use this space only)
r
r 1P
t�� 6/rl A o)tr ,5,S
I certify that the inform ion provided on this form is true.
Candidate Signature Date
j
Revised 312014
Anoka County
PROPERTY RECORDS & TAXATION DIVISION
Elections & Voter Registration
Candidate Name Pronunciation Form
The AutoMARK ballot marking device is used in Minnesota precincts to assist individuals with disabilities to vote
privately and independently. Users can choose to view their ballot and mark their choices on a touch screen,or
they can listen to an audio version of their ballot and select candidates using a Braille keypad.
In order to ensure the accuracy of our audio ballot,we ask all candidates to provide the phonetic spelling of their
name,as it appears on the Affidavit of Candidacy.
Name of Candidate:
How to pronounce name(e.g."rhymes with"boat"or"h"is silent):
Office sought:
Date:
Respectful, Innovative; Fiscally Responsible
2100 3`°Avenue A Anoka, MN 55303 a www.anokacounty.us/elections
elections@co.anoka.mn.us ♦ 763-324-1300 A FAX: 763-324-1160
Affirmative Action/Equal Opportunity Employer