2-21 Prescribed by Secn!Uiry of State

Section 141.031, Chapters 143 and 144, Texas Election Code 1/2017

ALL INFORMATION IS Rt:niiiRm TO BE PROVIDED UNLESS INDICATED OPTIONAL

APPUCATION FOR A PlACE ON THE ~ · r v , ~ <: n A' 11 M11 /JL GENERAL ELECTION BALLOT TO: City Secretary/Secretary of Board

I request that my name be placed on the above-named official ballot as a candidate for the office indicated below.

OFFICE SOUGHT (Include any place number or other distinguishing number, if any.) INDICATE TERM r-.:. ~-

C /;;; {uun <--/I /);'~!;, d I ~::::~.'"'" : , ~_.:; FULL NAME (First, Middle, last)

ku;-o A. £u.>h/lJ~· ~/; PERMANENT RESIDENCE ADDRESS (Do not include a P.O. Box or Rural Route. If you do not have a residence address, describe the address

at which you receive personal mail and location of residence.)

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CllY

~ ;>'t A .. ?"n ,·~ STATE ZIP

PRINT NAME AS YOU WANT IT TO APPEAR ON THE lf@.LOT:.;! ~;. 1:-~~

/. - /A J-- /} A 8 / A '5' ~in d,;flrl._. PUBLIC MAILING ADDRESS (Campaign mailing addres"S;;Jf av~i!~bfeJ.

31/ S" )7' ~'j'f ~ ""~~· s~,--r 11 R.

7'f?J...6 I

STATE ZIP

~ 7~2t1/ PUBLIC EMAIL ADDRESS (If available) OCX:UPATION (Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID

NUMBER (Optional) 2

j.. f3 / (j".J-.O I B~ako z Co/11 /llkr )I e,Y TELEPHONE CONTACT INFORMATION (Optional) Home:

Work:

l£NGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN

INSTATE IN TERRITORY FROM WHICH THE

OFFICE SOUGHT IS ELECTED3

M year (s) !j__ year (s)

Cell: ?-. I 0 7 7 '-/ / 7 #"" J L' I L' ..:} '- L month(s) .sz_ month(s)

If using a nickname as part of your name to appear on the ballot. you are also signing and swearing to the following statements: I further swear

that my nickname does not constitute a slogan nor does it indicate a political, economic. social, or religious view or affiliation. I have been commonly known by this nickname for at least three years prior to this election.

Before me, the undersigned authority, on this day personally appeared (name) L..4o rtJ A-/3 u 5'£.' m IIi 11 f. who being by me

here and now duly sworn, upon oath says: /; •

"I, (name) /.._4 u Fd 4· ~ t-1 ~~.,;\ ll e of ~ Y e! ),...-- County, Texas, being a candidate for the office of ?/); ~ .. 11 ~ • -,-r; • · (i I . swear that I will support and defend the Constitution and laws

of the United States and of the State of Texas. I am a citizen of the United States eligible to hold such office under the constitution and laws of this state. I have not been finally convicted of a felony for which I have not been pardoned or had my full rights of citizenship restored by other official action. I have not been determined by a final judgment of a court exercising probate jurisdiction to be totally mentally incapacitated or partially mentally incapacitated without the right to vote. I am aware of the nepotism law, Chapter 573, Government Code.

1 further swear that the foregoing statements included in my appiXication a:; things :e an~/ ~~~

~ .h //__.._./ fo.--l_p~:.-<·~~.t;f_ ~ SIGI'fATURE Of CANOl[~~··· ~v v~ :·. «'.~

TO BE COMPLETED BY 01Y SECRETARY OR SECRETf.m:~!4RJ>:q I .-1 -u._ -.~A,..L ) ~..s>' (SeeSectionl.007) {~@l:.,t ~r )~

/ Da Rece· ~~f_,.~lru_re_o~~r~-re~~F-------------------

Voter Registration Status Verified M'

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SAN ANTONIO

~ Supplemental Documentation Required to be Submitted with

Application for a Place on the Ballot

Notice to all Applicants for a Place on the Ballot:

In accordance with Ordinance 2017-11-30-0920, all candidates seeking office must file an Application for a Place on the Ballot and are required to submit two (2) supplemental documents for the purposes of residency verification by the Office of the City Clerk. The address listed on your Application for a Place on the Ballot must match the address listed on your Supplemental Documentation.

Supplemental Documentation to be utilized for residency verification includes:

o Valid Voter Registration Certificate

o Current Utility Bill

/ Current Bank Statement

o Government Check

o Original Paycheck

/ Other Current Government-Issued Document with Name and Address

(.._ :....,.

0 co

Signature of this document is an acknowledgment of having read its terms and will serve as authority to access and use these records for the purpose of verifying the truth of the Affidavit of Residency. In signing this document, you are acknowledging that the documentation submitted is now a public record subject to the Texas Public Information Act. This form (Supplemental Documentation Form) shall be published with your Application for a Place on the Ballot on the Office of the City Clerk's Election Webpage.

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- ... 1 \ ... __ _ ~i~ .. :.:. ;;:: ::,. I ..

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Printed Name of Applicant /,,., tA ro A _ t:__, :fd/71 4 tlle_ ApplicantSignature: ~d.~~

Date: 1 I J.._ 1. I / I 1 J I

Prepared by the Office of the City Clerk -November 2018