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AFFIDAVIT OF CANDIDACY (City of Edina)

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White Copy – Filing Officer Yellow Copy – CFPD Board Pink Copy – Public Information Goldenrod Copy – Candidate Rev. 5/2015
Office of the Minnesota Secretary of State
AFFIDAVIT OF CANDIDACY
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)
Office Sought
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
City
State
Zip Code
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. I have attached a separate form listing my residence address.
Campaign Address and Contact
Candidate Phone Number (Required)
Campaign Contact Address (Required for those who have checked the box above):
Street Address
City
State
Zip Code
Website
Emai
l
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_______________
Subscribed and sworn to before me this _________ day of ______________________________, 20________.
__________________________________________________________________
Notary public or other officer empowered to take and certify acknowledgement (Notary stamp)
Filing # ______________
Cash/Check # _________
Amount $ ____________
Office of the Minnesota Secretary of State
Revised 2/2014
ADDRESS OF RESIDENCE FORM
Instructions
This form is to be attached to the Affidavit of Candidacy when a candidate has checked the Private Data box.
The address of residence is classified as private data at the request of the candidate. The address of residence is
us
ed by the filing officer who received the affidavit of candidacy, upon written request of a registered voter, to
determine whether the address of residence listed by the candidate is actually located in the area represented by
the office sought, pursuant to Minnesota Statutes, section 204B.06, subd. 1b (b). While the candidate is not required
to provide the address of residence, failure to provide the address of residence will result in an incomplete affidavit
of candidacy and the rejection of the affidavit of candidacy, which will result in the omission of the candidate’s name
from any ballot in the election for which the candidate attempts to file the affidavit of candidacy and pay the filing
fee. This information will be available to the filing officer to whom the written request is delivered, to employees of
that filing officer and to other elections officials with whom that filing officer consults in order to obtain information
necessary to make the determination whether the address of residence listed by the candidate is actually located in
the area represented by the office sought.
Candidate and Address of Residence
Candidate Name
Office Sought
S
treet
Address
City
MN ZIP Code
Statement
Pursuant to Minnesota Statutes 204B.06, subd. 1b (c), I have requested that my address of residence be classified as
private data. I certify that a police report has been submitted, or I have an order for protection regarding my safety
or my family’s safety.
Signature of candidate
D
ate
CAMPAIGN FINANCIAL REPORT
(All of the information in this report is public information)
Name of candidate, committee or corporation _____________________________________________________________
Office sought or ballot question ________________________________________ District __________________________
Type of
report
_______________ Candidate report
_______________ Campaign committee report
_______________ Association or corporation report
_______________ Final report
Period of time covered by report:
from __________ to __________
CONTRIBUTIONS RECEIVED
Give the total for all contributions received during the period of time covered by this report. Contributions should be listed by type
(money or in-kind) rather than contributor. See note on contribution limits on the back of this form. Use a separate sheet to itemize all
contributions from a single source that exceeded $100 during the calendar year. This itemization must include name, address, employer
or occupation if self-employed, amount and date for these contributions.
CASH
IN-KIND
TOTAL AMOUNT RECEIVED
$ ________________
+
$ ________________
=
$ _______________
TOTAL CASH-ON-HAND $ _______________
DISBURSEMENTS
Include the amount, date and purpose for all disbursements made during the period of time covered by report.
Attach additional sheets if necessary.
Date
Purpose
TOTAL
CORPORATE PROJECT EXPENDITURES
Corporations must list any media project or corporate message project for which contribution(s) or expenditure(s) total
more than $200. Submit a separate report for each project. Attach additional sheets if necessary.
Project title or description ____________________________________________________________________________
Date
Purpose
Name and Address
of Recipient
Expenditure or
Contribution
Amount
TOTAL
I certify that this is a full and true statement. ______________________________________________________________
Signature Date
Printed Name ____________________________ Telephone__________________ Email (if available)________________
Address ___________________________________________________________________________________________
For Office Use Only: Name Office Report
INSTRUCTIONS
(Reference: Minnesota Statutes, Chapters 211A and 211B)
This CAMPAIGN FINANCIAL REPORT is for use by candidates and committees for county, municipal, school district and special
district office who receive contributions or make disbursements of more than $750 in a calendar year; committees or corporations
spending more than $750 for or against a ballot question in a calendar year; and corporations spending more than $200 on
activities to encourage participation in precinct caucuses, voter registration or voting.
Where to file this report:
Hospital Districts
Park Districts
School Districts
Townships
Cities
Soil & Water Conservation Districts
Counties
The municipal (city or town) clerk – same place where filed affidavit of candidacy
The county auditor or municipal clerk – same place where filed affidavit of candidacy
School district clerk
Town clerk
City clerk
County auditor
County auditor
Candidate or committee report: The initial report must be filed within 14 days after the candidate or committee receives contributions
or makes disbursements of more than $750 in a calendar year. Subsequent reports must be filed.
During an Election Year - An “election year” is any year in which the candidate’s name or a question appears on the ballot.
In such a year (if an initial report has been filed) reports are required to be filed:
10 days before the primary or special primary
10 days before the general election or special election
30 days after a general election or special election
By January 31 of each year following the year when the initial report was
filed.
During a non-election year - By January 31 of each year following the year when the initial report was filed.
Once a final report* is filed, no further subsequent reports are required to be filed.
CONTRIBUTIONS: Means anything of monetary value that is given or loaned to a candidate or committee for a political purpose.
“Contribution” does not include a service provided without compensation by an individual. Each candidate or committee must list the
total amount of cash-on-hand designated to be used for political purposes as of the close of the reporting period.
CONTRIBUTION LIMITS: Candidates or candidate’s committees for county, municipal, school district offices may not accept aggregate
contributions in excess of $600 in an election year or in excess of $250 in a non-election year made or delivered by an individual or
committee. However, candidates seeking election from districts with a population in excess of 100,000 may not accept aggregate
contributions in excess of $1,000 in an election year and $250 in a non-election year.
BALLOT QUESTIONS: Any political committee, association or corporation that makes a contribution or expenditure to promote or defeat
a ballot question as defined in Minnesota Statutes, section 211A.01 shall file reports with the filing officer responsible for placing the
question on the ballot. Reports must be filed within 14 days of receiving contributions or making disbursements of more than $750 in one
calendar year, using the same schedule as above.
CONGRESSIONAL CANDIDATES: Candidates for election to the United States House of Representatives and Senate and any committee
raising funds exclusively on behalf of any one of those candidates may file copies of the reports required by federal law in lieu of those
required by Minnesota Statutes Chapter 211A.
CORPORATE ACTIVITIES TO ENCOURAGE PARTICIPATION: Corporations may contribute to or conduct public media projects to encourage
individuals to attend precinct caucuses, register or vote if the projects are not controlled by or operated for the advantage of a candidate,
political party or committee. The total amount of expenditures or contributions for any one project greater than $200, together with the
date, purpose and the names and addresses of the persons receiving the contribution or expenditures must be reported. Reports must be
filed with the Secretary of State, 180 State Office Building, St. Paul, MN 55155-1299, using the same schedule as above.
*FINAL REPORT: A final report may be filed any time after the candidate, committee or corporation has settled all debts and disposed of
all assets in excess of $100 in the aggregate. Check final report under “type of report”.
PROHIBITED TRANSFERS: Candidates for county, municipal, school district or special district offices may not accept contributions from
the principal campaign committees of any candidate for legislative, judicial or state constitutional office. In addition, a candidate may not
make contributions to the principal campaign committee of any candidate for legislative, judicial or state constitutional office unless the
contributions are made from the candidate’s personal funds.
STATE CANDIDATES: Candidates and committees for state constitutional offices, the state legislature, supreme court, court of appeals,
district court and committees for state constitutional amendments are governed by Minnesota Statutes Chapter 10A. Contact the State
Campaign Finance and Public Disclosure Board for further information at (651) 539-1180.
Note: The filing officer must restrict public access to the address of any individual who has made a contribution that exceeds $100 and
who has filed with the filing officer a written statement signed by the individual that withholding the individual’s address from the
financial report is required for the safety of the individual or the individual’s family.
Updated 7/18/2014
Office of the Minnesota Secretary of State
Revised 2/2014
CAMPAIGN FINANCIAL REPORT CERTIFICATION OF FILING
Instructions
Each county, municipal or school district candidate or treasurer of a committee formed to promote or defeat a
ballot question shall certify to the filing officer that all reports required by Minnesota Statutes 211A.02 have been
submitted to the filing officer or that the candidate or committee has not received contributions or made
disbursements exceeding $750 in the calendar year. The certification shall be submitted to the filing officer not later
than seven days after the general or special election. (Minnesota Statutes 211A.05, subdivision 1)
Campaign Information
Name of candidate or committee
Office sought by candidate (if applicable)
Identification of ballot question (if applicable)
Certification
Select the appropriate choice below, and sign.
I do swear (or affirm) that all campaign financial reports required by Minnesota
Statutes 211A.02 have been
submitted to the filing officer.
I do swear (or affirm) that all campaign contributions or disbursements did not exceed $750 in the calendar
year.
Signat
ure of candidate or committee treasurer
Date
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AFFIDAVIT OF CANDIDACY (City of Edina)

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Completed 13 August 2020

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