SOUTH DAKOTA SECRETARY OF STATE ● ATTENTION ELECTIONS ● 500 E. Capitol Ave. ● Pierre, SD 57501
www.SDSOS.gov ● phone 605 773 3537 ● fax 605 773 6580 ●
ELECTIONS@STATE.SD.US Last updated 07/01/2019
Conflict of Interest
CANDIDATE
Statement of Financial Interest
Deadline to file: Within 15 days after filing nominating petitions (Supreme Court Justice files within 15 days of
notifying Secretary of State of his intention to place his name on the retention ballot) or certification of convention
nomination.
File with: The SECRETARY OF STATE except local candidates file with the office where they file their nominating
petition.
Candidates who file: State and Federal Office candidates (United States Senate, United States House of
Representatives, Governor, State Legislator, circuit court judge and Supreme Court Justice SDCL 12-25-28);
Convention Nominee candidates (Lieutenant Governor, state treasurer, attorney general, secretary of state, state auditor,
public utilities commissioner, commissioner of school and public lands SDCL 12-25-29
);
Convention Nominee candidates of a party with alternative political status (US Senate, US House, Governor,
Lieutenant Governor, state treasurer, attorney general, secretary of state, state auditor, public utilities commissioner,
commissioner of school and public lands or state legislator SDCL 12-25-29.1
); and
Local Office candidates (county commissioner, school board member in a school district with a total enrollment of more
than 2,000 students, or commissioner, council member, or mayor in any 1
st
class municipality SDCL 12-25-30)
Please print:
Full Name _________________________________________________________________________________________
COMPLETE Address ________________________________________________________________________________
Office Sought (list District number if applicable) __________________________________________________________
What is your occupation/profession? ____________________________________________________________________
List any source of funds (business or economic relationship) which contributes more than 10% of or more than $2,000
to your family’s (includes spouse, minor children living at home) gross income in the preceding calendar year. This also
includes any enterprise in which you or an immediate family member(s) controls more than 10% of the capital or stock.
Identify who receives the income from each enterprise but do not include the value. (SDCL 12-25-27
)
*The intent of this form is to collect specific information, not generalities. Do not put N/A or leave the grid blank.
Name of Candidate or
Family Member
(Ex: current employer, SD Legislature, 401K,
(Ex: employee, officer, director, associate, partner,
shareholder, owner, member, proprietor, etc.)
I declare and affirm under the penalties of perjury that the information above has been examined by me and to the best of
my knowledge and belief is a true, correct and complete representation of myself and my immediate family’s financial
interests for the preceding calendar year.
________________________________________________ _______________________________
(Signature) (Date)
