Form Jcvp-01 - Candidate'S Statement For County Voters' Pamphlet Page 5
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6JCVP‐01
ORS 251.335
Candidate’s Statement for County Voters’ Pamphlet
Important! Please read all instructions before completing this form. This form is to be used when filing a ‘Candidate’s Statement for
County Voters’ Pamphlet’ with your County Elections office. Please note that each county produces a separate County Voters’
Pamphlet. If the jurisdiction or district is located in more than one county a separate ‘Candidate’s Statement for Voters’ Pamphlet’
form must be filed and the fee paid to each county where the statement is to be printed.
FILING INFORMATION
Election
: Primary 20_____ General 20_____ Special___________________
Original Statement Amended Statement
Name of Candidate
(as it will appear on ballot):
Filing for the Office of
(what’s applicable):
District: Position: Zone #:
“This Information Furnished by” (required: name of Candidate or Committee as should appear in Voters’ Pamphlet):
CONTACT INFORMATION
Phone: Cell: Work: Home:____________________
E‐Mail:
Warning: Any person who supplies information in the ‘Required’ portion of a Voters’ Pamphlet statement, knowing it to
be false, is subject upon conviction, of a Class C felony, to imprisonment for up to five years or to a fine of $125,000, or
both. ORS 260.715 (1); 260.993 (2); 161.605; and 161.625.
Note: Language which violates any provision of ORS 251.415 will be excluded from the Voters’ Pamphlet.
By signing this document, I hereby state:
‐ That all information provided by me on this form and in this Statement is true to the best of my knowledge;
‐ I am the author of this Statement (ORS 251.415);
‐ I have read and understand the instructions for submitting this ‘Candidate Statement’; and
‐ The portrait provided, if any, is less than four (4) years old.
_______________________________________________________________
___________________, 20_____
Signature of Candidate or Agent on behalf of Candidate
Date signed
________________________________________________________________________
) Printed name of Agent
Phone number
(If applicable
For Office Use only:
County:__________________
Optional Info? Yes No
Intake Staff Initials:
Endorsements? Yes #_____ No
Cash‐receipt #:____________
Portrait?
Word Count (325 max):
Check #:__________________
Print? #______
Amount $______________
Email?
Digital copy? Yes No
Required Info? Yes No
Copy? Yes No
Review Staff Initials:
None
Signed? Yes No
Rev 02 201
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