Fill - Free fillable Form 2021: Linn County Election Office PDF form

Linn County Election Office

David Lamb, County Clerk/Election Officer

315 Main Street / P.O. Box 350

Mound City, KS 66056

Phone: (913) 795-2668

Fax: (913) 795-2419

2021

Extension District Election

• The General Election will be held on November 2, 2021.

• Extension District Candidates must file by payment of a $20

filing fee.

• Candidates must complete a Declaration of Intention (KSA 25-

205 & 25-21a01), a Statement of Substantial Interest for Local

Office (KSA 75-4302a), and an Affidavit of Exemption (KSA 25-

904a), if the candidate anticipates receiving and/or spending

less than $1,000 in the Primary and $1,000 in the General. If the

candidate anticipates receiving and/or spending $1,000 or more

in either election, the candidate must file and itemized

statement of all receipts and expenditures.

• Candidates must be a qualified elector as of election day.

• The filing deadline is June 1, 2021 at Noon (KSA 25-21a03-

Amended by SB 130). No candidate is permitted to withdraw

from candidacy after the filing deadline (KSA 25-2106).

Candidates must file with the County Clerk’s office.

1. Name

List exactly as it will appear

on ballot, including all

punctuation.

2. City

3a. Ofce sought 3b. District

Number

4. Term

o

Regular

o

Unexpired

5. Preferred title

Used for mailing purposes.

o

Mr.

o

Mrs.

o

Ms.

o

Dr.

6. Residential address

Provide a street or rural route.

Do not leave blank.

Address

City County Zip

7. Mailing address

Complete if mailing address is

different from above.

Address

City State Zip

8. Telephone number

Home Work Cell

9. Email address

10. I declare that I intend to become a candidate for the above-stated ofce at the appropriate election.

Signature of Candidate

X

Today’s

Date:

Mo. Day Yr.

County Election Ofcer or City Clerk

X

Deputy Election Ofcer

X

kansas sec r e ta ry of state

City/School Candidate’s

Declaration of Intention

CS

1 / 1

K.S.A. 25-2020, 25-2110, 25-2110a

Rev. 12/06/10 jdr

Please review to ensure completion.

STATEMENT OF SUBSTANTIAL INTERESTS FOR LOCAL OFFICE

INSTRUCTIONS. This statement must be completed by each person required to do so by K.S.A. 75-4301a. Upon

completion, mail or hand deliver your completed statement to the office where you filed your declaration of candidacy. If

appointed to fill a vacancy in a local elective office, file this form where your predecessor filed for office.

PLEASE TYPE OR PRINT

A. IDENTIFICATION:

Last Name First Name MI

Spouse's Name

Number & Street Name, Apartment Number, Rural Route, or P.O. Box Number

City, State, Zip Code

Home Phone Business Phone

B. OFFICE SOUGHT, HELD OR APPOINTED TO:

List Name of Office

Position District

CONTINUED ON NEXT PAGE

Date received (Official use only)

Governmental Ethics Commission Rev. 2001

2

C. OWNERSHIP INTERESTS: List any corporation, partnership, proprietorship, trust, joint venture and every other

business interest, including land used for income, and specific stocks, mutual funds or retirement accounts in which

either you or your spouse has owned within the preceding 12 months a legal or equitable interest exceeding $5,000 or

5%, whichever is less. Please attach additional pages if necessary to complete this section.

If you have nothing to report in Section "C", check here ____.

BUSINESS NAME AND ADDRESS TYPE OF BUSINESS DESCRIPTION OF

INTERESTS HELD

HELD BY

WHOM

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

D. GIFTS IN THE FORM OF GOODS OR SERVICES: List any person, business or combination of businesses

from which you or your spouse either individually or collectively, have received in the preceding 12 months, without

reasonable and valuable consideration, goods or services having an aggregate value of $500 or more.

If you have nothing to report in Section "D", check here ____.

NAME OF PERSON OR BUSINESS FROM WHOM GIFT

RECEIVED

ADDRESS RECEIVED BY:

1.

2.

3.

3

E. RECEIPT OF COMPENSATION: List all places of employment in the last calendar year, and any other businesses

from which you or your spouse received $2,000 or more in compensation (salary, thing of value, or economic benefit

conferred on you or your spouse in return for services rendered, or to be rendered), which was reportable as taxable

income on your federal income tax returns.

1. YOUR PLACE(S) OF EMPLOYMENT OR OTHER BUSINESS IN THE PRECEDING CALENDAR

YEAR.

If you have nothing to report in Section "E"1, check here ____.

NAME OF BUSINESS ADDRESS TYPE OF BUSINESS

1.

2.

2. SPOUSE'S PLACE(S) OF EMPLOYMENT OR OTHER BUSINESS IN THE PRECEDING

CALENDAR YEAR.

If you have nothing to report in Section "E"2, check here .

NAME OF BUSINESS ADDRESS TYPE OF BUSINESS

1.

2.

F. OFFICER OR DIRECTOR OF AN ORGANIZATION OR BUSINESS: List any organization or business in

which you or your spouse hold a position as officer, director, associate, partner or proprietor at the time of filing,

irrespective of the amount of compensation received for holding such position. Please insert additional pages if

necessary to complete this section.

If you have nothing to report in Section "F", check here ____.

BUSINESS NAME AND ADDRESS POSITION HELD HELD BY

WHOM

1.

2.

3.

4.

5.

4

G. RECEIPT OF FEES AND COMMISSIONS: List each client or customer who paid fees or commissions to a

business or combination of businesses from which fees or commissions you or your spouse received an aggregate of

$2,000 or more in the preceding calendar year. The phrase "client or customer" relates only to businesses or the

combination of businesses. In the case of a partnership, it is the partner's proportionate share of the business, and

hence of the fee, which is significant, without regard to the expenses of the partnership. An individual who receives a

salary as opposed to portions of fees or commissions is generally not required to report under this provision. Please

insert additional pages if necessary to complete this section.

If you have nothing to report in Section "G", check here ____.

NAME OF CLIENT / CUSTOMER ADDRESS RECEIVED BY

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

H.

DECLARATION:

I, , declare that this statement of substantial interests (including any

accompanying pages and statements) has been examined by me and to the best of my knowledge and belief is a true,

correct and complete statement of all of my substantial interests and other matters required by law. I understand that

the intentional failure to file this statement as required by law or intentionally filing a false statement is a class B

misdemeanor.

Date Signature of Person Making Statement

NUMBER OF ADDITIONAL PAGES .

AFFIDAVIT OF EXEMPTION

FROM FILING RECEIPTS AND EXPENDITURES REPORTS

BY A CANDIDATE FOR:

THIRD CLASS CITY, UNIFIED SCHOOL DISTRICT, AND TOWNSHIP OFFICE

IF YOU ANTICIPATE RECEIVING OR EXPENDING $1,000 IN THE PRIMARY, EXCLUSIVE OF THE CANDIDATE FILING

FEE, OR $1,000 IN THE GENERAL ELECTION, THIS FORM MAY NOT BE USED.

Instructions. This form may be used by the any candidates for office in cities of the 3

rd

class, school boards, or a township who

qualifies for the exemption. It must be filed with your County Election Officer prior to the ninth day before the Primary Election.

(Not later than ten (10) days after becoming a candidate.) These candidates need not appoint a treasurer but must maintain records

required by K.S.A. 25-904.

PLEASE PRINT OR TYPE

A. Name of Candidate ____________________________________________________________________________________

Address ____________________________________________ City _________________________ Zip Code___________

Home Telephone _____________________________________Business Telephone________________________________

Office Sought ________________________________________District (if applicable)_______________________________

B. Affidavit:

State of Kansas

County of LINN

I, _________________________________________________________, do swear (or affirm) that:

1. The information in Item A above is true and correct;

2. I intend to expend, contract to expend, or have expended, on my behalf an aggregate amount or value of less than

one thousand dollars ($1,000) in the primary election period; and

3. I intend to receive or have received on my behalf (including amounts contributed by myself) contributions of an

aggregate amount or value of less than one thousand dollars ($1,000) in the Primary Election period; and

4. I understand that the payment of my filing fee, or the receipt of funds to pay my filing fee, is not included in the

limitations set forth in paragraphs 2 & 3; and

5. I intend to expend, contract to expend or have expended on my behalf an aggregate amount or value of less than

one thousand dollars ($1,000) in the general election period; and

6. I intend to receive or have received on my behalf (including amounts contributed by myself) contributions of an

aggregate amount or value of less than one thousand dollars ($1,000) in the General Election period; and

7. If contributions are received or expenditures made (actual or contractual) in excess of any of the amounts set out

above, I shall within thirty (30) days of the date of such excess file with the County Election Officer an itemized

statement under oath stating the name and address of each person who has made any contribution in excess of $50

during the election period together with the amount and date of such contributions in and itemized statement of all

expenditures made by such candidate or obligations contracted or incurred by such candidate in connection with each

Primary or General Election required by K.S.A. 25-904.

____________________ ___________________________________________

(Date) (Signature of Candidate)

Subscribed and sworn to (affirmed) before me this _______day of _______________________, 20______________

______________________________________________

(Notary Public)

(Seal) My Appointment Expires ______________________, 20______

• EXAMPLE 1:

Candidate A intends to receive contributions of less than $1,000 and make expenditures

of less than $1,000 in the primary election period. Candidate A does, however, intend to

receive contributions in excess of $1,000 during the general election period. He also

intends to make expenditures (either actual or contractual) of more than $1,000 during the

general election period. Candidate A cannot properly file the affidavit of exemption. He

must file all reports at the times required by K.S.A. 25-4148.

• EXAMPLE 2:

Candidate B meets all of the tests for exemption from filing the reports but fails to file the

affidavit until after the date the first report for the primary election is due. Candidate B

must file all reports since the affidavit was not filed in a timely manner.

• EXAMPLE 3:

Candidate C intends to receive contributions and make expenditures of less than $1,000

in each the primary and general election period; however, the $1,000 limit was exceeded

during the general election period. Candidate C shall within three (3) days of the date of

such excess file all past due reports and shall file all such future reports on the dates

required by K.S.A. 25-4148.

IF YOU HAVE ANY QUESTIONS CONCERNING THIS AFFIDAVIT,

PLEASE CONTACT THE

GOVERNMENTAL ETHICS COMMISSION

901 S. Kansas Avenue

Topeka, Kansas 66612

Office (785) 296-4219

Fax (785) 296-2548

Fill Online, Printable, Fillable, Blank Form 2021: Linn County Election Office Form

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Fillable Form 2021: Linn County Election Office

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