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Office of the Minnesota Secretary of State Filing#
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AFFIDAVIT OF CANDIDACY
Instructions r Amount$
I information on this form is available to the public.Information provided will be published on the Secretary of State's website.If filing for
artisan office and not a major party candidate,you must file both an affidavit of candidacy and a nominating petition.(Minn.Stat.2048.03)
Candidate Information
Name and Office
Candidate Name(as it will appear on the ballot)
Office Sought � ,} t 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,
x
City) ,,.. . . State w 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 .P
Candidate Phone Number(Required)]
Campaign Contact Address(Required for those who have checked the box above);
Street Address;
Cit Y State Zip Code
,: .
QfebsiteF�;�
,Email
firmation
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 J 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
d a copy of my license is attached.
• School Board Member—I have not 'een convicted of an offense for which registration is required under Minn.Stat.243.166.
y, p t or S at -ri ffice—I meet any other qualifications for that office prescribed by law.
• Count M i al,School District
Cand date gna re Date
ibe s rn to be me this day of 0 20
Lori J.Hensen
NOTARY PUBLIC
MINNESOTA
p b is or er r mpowered to take and certify acknowledgement s.+ 4M �es Jan.31,2027
White Copy—Filin fficer Yellow Copy—CFPD Board Pink Copy—Public Information Goldenrod Copy—Candidate Rev.5/2015
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�,.SFA""r OFFICE OF THE MINNESOTA SECRETARY OF STATE
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CANDIDATE NAME PRONUNCIATION FORM
Candidate's Name (clearly print): ACJV1x 6
Office Filed For(clearly print): � ��
Type of District(circle one):
Federal State Judicial County S&WCD City Township School Hospital Park Other
District District District
District's Name (clearly print):
Candidate Name's Pronunciation:
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Additional Notes:
Info of Staff Member completing this form:
Name and Title:
Name of Your Jurisdiction:
Date completed:
Date submitted to County Auditor's Office:
Date submitted to ERS Data-Entry Staff Member:
• Date entered into ERS:
Form updated 5/18/2020