Official Filing Form and Nomination Petition

7/31/2019 Official Filing Form and Nomination Petition

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OFFICIAL FILING FORM MUNICIPAL

City:PAGE 1 OF 3

AFFIDAVIT OF NOMINEE & OATH OR AFFIRMATION OF NOMINEE Issued by:

SIGNATURE

AFFIDAVIT OF NOMINEE

State of California TITLE

County of Riverside } ss. Date:

I, , under penalty of perjury, state that I am a nominee for the office

of

Ward or Councilmanic District Full Term Short Term

I will accept the office in the event of my election to this office at the election to be held on November 6, 2012

I desire my name to appear on the ballot as follows:

PRINT OR TYPE YOUR NAME

and I desire the following designation to appear on the ballot under my name:

(Print or type your principal profession(s), vocation(s), or occupation(s), in 3 words or less; or the name of the elective public office youhold or Incumbent. If you leave this space blank, no designation will appear on the ballot.)

My residence address is as follows:

RESIDENCE ADDRESS: NUMBER, STREET, CITY & ZIP

MAILING ADDRESS, IF DIFFERENT

SIGNATURE OF NOMINEE

( ) ( ) ( )

DAY TELEPHONE NUMBER EVENING TELEPHONE NUMBER FAX

EMAIL ADDRESS:

OATH OR AFFIRMATION OF NOMINEE

I do solemnly swear (or affirm) that I will support and defend the Constitution of the United States and theConstitution of the State of California against all enemies, foreign and domestic; that I will bear true faith andallegiance to the Constitution of the United States and the Constitution of the State of California; that I take thisobligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the

duties upon which I am about to enter.

State of California

County of Riverside} ss.

SIGNATURE OF NOMINEE

Subscribed and sworn to before me this day of , 20

SIGNATURE OF OFFICER ADMINISTERING OATH

TITLE OF OFFICER ADMINISTERING OATH


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PAGE 2 OF 3 NOMINATION PAPER

We, the undersigned voters of the City of , Ward/District (if applicable) , hereb

nominate for the office of

Full Term Short Term of said City, to be voted on at the election to be held on November 6, 2012DATE OF ELECTION

NAME RESIDENCE ADDRESS FOR OFFICE USE

SIGN NO. & STREET

1PRINT CITY ZIP

SIGN NO. & STREET

2PRINT CITY ZIP

SIGN NO. & STREET

3PRINT CITY ZIP

SIGN NO. & STREET4

PRINT CITY ZIP

SIGN NO. & STREET5

PRINT CITY ZIP

SIGN NO. & STREET

6PRINT CITY ZIP

SIGN NO. & STREET

7PRINT CITY ZIP

SIGN NO. & STREET

8PRINT CITY ZIP

SIGN NO. & STREET

9PRINT CITY ZIP

SIGN NO. & STREET

10PRINT CITY ZIP

SIGN NO. & STREET

11PRINT CITY ZIP

SIGN NO. & STREET

12PRINT CITY ZIP

SIGN NO. & STREET

13PRINT CITY ZIP

SIGN NO. & STREET

14 PRINT CITY ZIPSIGN NO. & STREET

15PRINT CITY ZIP

SIGN NO. & STREET

16PRINT CITY ZIP

IMPORTANT! Turn to reverse side for signatures spaces 17-30 and Affidavit of Circulator, which must be filled out.

OFFICE USE ONLY

NO. OF VALID SIGNATURES


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PAGE 3 OF 3 NOMINATION PAPER & AFFIDAVIT OF CIRCULATOR

NAME RESIDENCE ADDRESS FOR OFFICE USE

SIGN NO. & STREET

17PRINT CITY ZIP

SIGN NO. & STREET

18PRINT CITY ZIP

SIGN NO. & STREET

19PRINT CITY ZIP

SIGN NO. & STREET

20PRINT CITY ZIP

SIGN NO. & STREET

21PRINT CITY ZIP

SIGN NO. & STREET

22PRINT CITY ZIP

SIGN NO. & STREET

23 PRINT CITY ZIP

SIGN NO. & STREET

24PRINT CITY ZIP

SIGN NO. & STREET

25PRINT CITY ZIP

SIGN NO. & STREET

26PRINT CITY ZIP

SIGN NO. & STREET

27PRINT CITY ZIP

SIGN NO. & STREET28

PRINT CITY ZIP

SIGN NO. & STREET

29PRINT CITY ZIP

SIGN NO. & STREET

30PRINT CITY ZIP

State of CaliforniaCounty of Riverside

} ss DECLARATION OF CIRCULATOR (IN CIRCULATORS OWN HAND)

I, , solemnly swear (or affirm) that the signatures on this nomination paper were

PRINTED NAME OF CIRCULATOR

obtained between , 20 , and , 20that I circulated this petition and I witnessed the signatures on this section of the nomination papers being written; and that, to the bestof my information and belief, each signature is the genuine signature of the person whose name it purports to be.

My residence and voting address is

I certify under penalty of perjury under the laws of the State of California that this declaration is true and correct.

Executed on , 20 at

Signature of Circulator

(INCLUDE FIRST, MIDDLE AND LAST NAME)

Official Filing Form and Nomination Petition

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