Form Sbe-501(4) - Certificate Of Candidate Qualification - Local Offices
ADVERTISEMENT
1
2Commonwealth of Virginia
CERTIFICATE OF CANDIDATE QUALIFICATION
NOTICE:
YOU MUST FILE THIS FORM WITH THE GENERAL REGISTRAR
.
BY THE FILING DEADLINE
FAILURE TO DO SO MAY RESULT IN
LOCAL OFFICES
.
.
YOUR DISQUALIFICATION
SEE REVERSE SIDE FOR DETAILS
Pursuant to § 24.2-501 of the Code of Virginia, I hereby certify that:
1. I am a citizen of the United States.
[ ]
[ ]
YES
NO
2. I am at least eighteen years of age or will be on or before the date of the election
[ ]
[ ]
YES
NO
for the office I am seeking.
3. I have been a resident of the Commonwealth of Virginia for the year immediately
[ ]
[ ]
YES
NO
preceding the election for the office I am seeking.
4. I now reside at the address shown below in the *county or city and, if applicable, district
[residence address must be given; post office box or general delivery is not acceptable]:
in which I seek office
___________________________________________________________
,
,
STREET AND NUMBER
RURAL ROUTE AND BOX NUMBER
OR HIGHWAY ROUTE NUMBER
City/Town ___________________________________ ZIP ___________
[If town, also list County of residence: ____________________________]
5. I am registered to vote at the above address in the precinct in which I reside.
[ ]
[ ]
YES
NO
[or my application for registration, transfer, or change of address is on file in the general registrar’s office]
6. Have you ever been convicted of a felony or any other crime that would preclude you
[ ]
[ ]
YES
NO
from holding office? (See, e.g., § 18.2-472)
7. Have you ever been adjudicated mentally incompetent and lost your right to vote?
[ ]
[ ]
YES
NO
8. If you answered YES to 6, give date of certificate restoring voting rights.
______________________
If YES to 7, give date of court order restoring competency.
DATE OF RESTORATION
9. I am an attorney admitted to the bar of the Commonwealth.
[ ]
[ ]
YES
NO
(Answer only if seeking office of Commonwealth's Attorney)
OFFICE
PLEASE TYPE OR PRINT LEGIBLY ALL THE FOLLOWING INFORMATION:
SOUGHT
YOUR NAME AS IT IS TO APPEAR ON BALLOT
DISTRICT
[
]
SEE REVERSE SIDE FOR REQUIREMENTS
IF APPLICABLE
YOUR SOCIAL SECURITY NUMBER
[
]
SEE STATEMENT ON REVERSE SIDE
(
/
/
)
ELECTION DATE
MM
DD
YYYY
MAILING OR CAMPAIGN ADDRESS
Republican Primary
Special Election
CHECK ONE
Democratic Primary
General Election
(
)
-
AREA CODE
HOME TELEPHONE
E
MAIL ADDRESS
(
)
AREA CODE
BUSINESS TELEPHONE
WEB ADDRESS
I do solemnly swear [or affirm] subject to penalty provisions for making false statements that the information given
above is true and correct and that I am qualified to vote for and hold the office for which I am a candidate.
___________________________________________________________
__________________
SIGNATURE OF CANDIDATE
DATE
PLACE PHOTOGRAPHICALLY REPRODUCIBLE
/
NOTARY SEAL
STAMP BELOW
State of
County/City of _______________________________
The foregoing instrument was subscribed and sworn before me this
day of
, 20
, by __________________________________________.
PRINT NAME OF CANDIDATE
________________________________________________
______________________
________________________
SIGNATURE OF NOTARY OR CLERK OF CIRCUIT COURT
NOTARY REGISTRATION NUMBER
DATE NOTARY COMMISSION EXPIRES
.
KNOWINGLY MAKING ANY UNTRUE STATEMENT OR ENTRY IN THIS DOCUMENT IS A FELONY UNDER VIRGINIA LAW
$2,500
/
.
,
.
THE PUNISHMENT IS A MAXIMUM FINE OF
AND
OR CONFINEMENT FOR UP TO TEN YEARS
ALSO
YOU LOSE YOUR RIGHT TO VOTE
*See §15.2-1525 of the Code of Virginia for certain exceptions to residence requirements for Commonwealth’s Attorneys.
INSTRUCTIONS ON REVERSE SIDE
SBE-501(4) REV 1/15
SEE
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 150-303-089 - Certification For Continued Qualification Of Conservation Easement Special Assessment
Financial
Form Lp-4 - Certificate Of Cancellation Of A Limited Partnership - West Virginia Secretary Of State
Legal
Related Categories
Parent category: Business