Form Sbe-501(6) - Certificate Of Candidate Qualification - General Assembly
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1
2Commonwealth of Virginia
NOTICE:
YOU MUST FILE THIS FORM WITH THE DEPARTMENT OF
CERTIFICATE OF CANDIDATE QUALIFICATION
.
ELECTIONS BY THE FILING DEADLINE
FAILURE TO DO SO
GENERAL ASSEMBLY
.
MAY RESULT IN 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 twenty-one years of age or will be on or before the date of the general or
[ ]
[ ]
YES
NO
special election 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 district in which I seek office
[residence address must be given; post office box or general delivery is not acceptable]:
___________________________________________________________
,
,
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 if not and registration books are closed, my application for registration, transfer, or change of
address is on file in the general registrar's office for processing when books re-open]
6. Have you ever been convicted of a felony?
[ ]
[ ]
YES
NO
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
PLEASE TYPE OR PRINT LEGIBLY ALL THE FOLLOWING INFORMATION:
OFFICE SOUGHT
YOUR NAME AS IT IS TO APPEAR ON BALLOT
DISTRICT NUMBER
[
]
SEE REVERSE SIDE FOR REQUIREMENTS
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 INSTRUCTIONS ON REVERSE SIDE
SBE-501(6) REV 1/15
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