Fillable Complaint Form/affidavit printable pdf download

AFFIDAVIT OF IDENTITY AND RECEIPT OF FILING

PLEASE COMPLETE SECTIONS I, II, III AND IV BELOW (Print or Type) – See Reverse Side for Important Notifications

OFFICE

Received by

No. of Petition Sheets or Receipt No

USE

Reviewed by

Date of Filing

ONLY

Jurisdiction/District of Office Sought

CFR I.D. No.

CANDIDATE IDENTIFICATION

Name

Birth date

(Last)

(First)

(Middle)

(Month)

(Day)

(Year)



Have you changed your name within the last 10 years for reasons other than marriage?

Yes

If yes, enter full former name here (See “Section A” on reverse)

I WISH TO HAVE MY NAME APPEAR ON THE BALLOT AS PRINTED BELOW

(Please print upper & lower case - nicknames/titles not permitted. See “Sec. B” on reverse.)

Residence Address (Street Address, City, Zip Code):

Mailing Address (See “Section C” on reverse):

(Street Address)

(City)

(Zip)

(City)

(Zip)

Phone (

)

Website



City



Township of

Precinct # (required)

and Ward # (if any)

County of

Resident of County for

years. Resident of Michigan for

years.



I am a citizen of the United States:

Yes



I am registered and qualified to vote at the address listed above:

Yes

II.

OFFICE SOUGHT

Office Title:



Date of Election: Primary Election *

General Election

Recall

(Month)

(Day)

(Year)

(Month)

(Day)

(Year)

If a partisan office, list political party*

District/Circuit # (if applicable)

(Note: If filing a Qualifying Petition list “No Party Affiliation”)



Term of Office

Regular Term

Partial Term

Expiring

(Month)

(Day)

(Year)

Judicial Candidates Only (See “Section D” on reverse)*



Incumbent Position



Non-Incumbent Position



New Judgeship

III.

FILER’S ACKNOWLEDGMENT –

This filing contains the following (check all that apply):



Nominating or Qualifying Petitions (Estimated number of signatures:

)

If nominating petitions are filed:



Filing Fee of $100.00 (if applicable)

Destroy petitions in January



Certification of Party Nomination and Certificate of Acceptance (if applicable)*



Return petitions in January



Affidavit of Constitutional Qualification (judicial candidates only)*



Affidavit of Candidacy (incumbent judicial candidates only)*

IV.

CAMPAIGN FINANCE COMPLIANCE STATEMENT AND ATTESTATION

•

By signing this affidavit, I swear (or affirm) that the facts I have provided are true. I further swear (or affirm) that the facts contained in the statement set forth

below are true. (See Section “E” on reverse for further information.)

At this date, all statements, reports, late filing fees, and fines due from me or any Candidate Committee organized to support my

election to office under the Michigan Campaign Finance Act, PA 388 of 1976, have been filed or paid.

•

I acknowledge that making a false statement in this affidavit is perjury – a felony punishable by a fine up to $1,000.00 or imprisonment for up to 5 years, or

both. (MCL 168.558, 933 and 936)

SIGNATURE OF CANDIDATE

Subscribed and sworn to before me on the ____________________________________ Name of Notary ______________________________________________

(Day)

of ______________________ _____________ Notary Public, State of Michigan, County of ________________________

My commission expires _______________________________________

(Month)

(Year)

Acting in the County of ________________________________________

______________________________________________________________________

Signature of notary public

*Not applicable to School Board Candidates