Statement Of Interests Page 4
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4SFN 10172 (10-2015)
Page 4 of 4
INSTRUCTIONS FOR STATEMENT OF INTERESTS
WHO FILES: The Statement of Interests must be filed by all candidates seeking to have their name placed on the ballot for federal, statewide,
judicial district, legislative, county, multi-district, city, and school district office. Every person appointed by the Governor to a state agency,
board, bureau, commission, department, or occupation or professional licensing board shall also file a Statement of Interests.
WHEN TO FILE: Every candidate for elective office must file a Statement of Interests with the appropriate filing officer at the same time as filing
his/her Certificate of Endorsement SFN 17196 or Petition/Certificate of Nomination SFN 2704 and Affidavit of Candidacy SFN 2703.
Appointees of the Governor shall file a Statement of Interests no later than the announcement of the appointment.
WHERE TO FILE:
FEDERAL, STATEWIDE, JUDICIAL, AND LEGISLATIVE DISTRICT CANDIDATES - File with the Secretary of State:
Secretary of State
State of North Dakota
600 E Boulevard Ave Dept 108
Bismarck ND 58505-0500
APPOINTEES OF THE GOVERNOR - File with the Secretary of State
COUNTY AND MULTI-DISTRICT CANDIDATES - File with the County Auditor in their county of residence
CITY CANDIDATES - File with the City Auditor
SCHOOL DISTRICT CANDIDATES - File with the School Business Manager
HOW TO FILE:
ITEM A - PRINCIPAL OCCUPATION: The occupations listed are those defined on the North Dakota state income tax return. Check only one
category for the principal source of income for yourself, and only one for your spouse. Please mark and complete the box labeled "Other" if you
or your spouse's occupation is not listed.
ITEM B - List by name each business or trust that is NOT the principal source of income, in which you and/or your spouse have a financial
interest. Include any of the following that apply:
1.
Any business or trust in which you and/or your spouse own a legal or equitable interest.
2.
Any business or trust in which you and/or your spouse have investments. Include the name of the business or trust of which you have
stocks, mutual funds, bonds, debentures, or debt obligations of corporations and/or municipal corporations. Financial interests that are
contained in diversified portfolios need only be mentioned by the brokerage establishment it is with.
3.
Any business or trust from which you and/or your spouse receive compensation.
4.
Any business or trust paying you and/or your spouse a fee or commission for professional or consulting services. Include those public
agencies from which you and/or your spouse received a fee or commission. Attorneys and others who list their principal occupation as
"professional" are not required to list clients.
5.
Public agencies (state or local) to which you and/or your spouse sold goods or services.
ITEM C - List the associations or institutions with which you and/or your spouse are closely associated, or serve as a director or officer of,
and which maybe affected by legislative action (for legislative candidates) or action of the officeholder of the office to which you are a candidate
or appointee.
List organizations and associations and note the capacity of you and/or your spouse's relationship such as "member", "board of
directors", "consultant", etc.
ITEM D - Identify by name any business office, business directorship, and fiduciary relationship that you and/or your spouse have held in
the preceding calendar year.
Fiduciary means acting as a guardian, trustee, executor, administrator, or conservator for any person, whether individual or corporate.
Specify the capacity of the relationship of you and/or your spouse for any of the listed businesses, trusts and/or fiduciary relationships,
such as "director", "executor", "trustee", etc.
SPECIAL NOTES:
Items B, C and D of this form have limited space for listing items. If you need more space, attach additional sheets in the same format
and clearly identify which of the three items (B, C or D) the additional sheet continues. Insert the additional sheets into this form.
Use an "X" to indicate the "interest" relationship for (a) yourself, or (b) your spouse.
You are not required to list dollar amounts or the nature of the work performed in ITEMS B, C or D.
ASSISTANCE: Questions regarding the Statement of Interests may be directed to the Elections Unit of the Secretary of State's Office at (701)
328-4146 or (800) 352-0867 or the appropriate filing officer.
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