Form B05j-A - Filing For Office Court Of Appeals Judicial Candidate Packet Page 3
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6STATE OF ALASKA DECLARATION OF CANDIDACY FOR RETENTION
COURT OF APPEALS
Please check: ___ My $100 filing fee accompanies this Declaration of Candidacy
Please check: ___ My Public Official Financial Disclosure Statement is on file with the Alaska Public Offices Commission.
NOTE: Candidates are encouraged to contact APOC to ensure they have a current Public Officials
Financial Disclosure Statement on file with APOC.
GENERAL INFORMATION (Please print or type)
I, ________________________________________________, declare that I am a candidate for retention to the office of:
JUDGE IN THE COURT OF APPEALS.
I request that my name be placed on the November 6, 2018 General Election ballot.
CONTACT INFORMATION
Mailing address and contact phone number for Candidate to be listed on the Division of Election’s website:
, _______ _____________ __________________
(Mailing Address)
(City)
(State)
(Zip)
(Phone Number)
I request that my name appear on the General Election ballot in the following manner:
,
_______________________________ _______ ______________________________
_________________________
(First Name)
(MI)
(Last Name)
(*Nickname and/or Suffix)
*The Director of Elections may not include on the ballot as part of candidate’s name, any honorary or assumed title or prefix but may
include in the candidate’s name any nickname or familiar form of a proper name of the candidate. [AS 15.15.030(4)]
CERTIFICATION
I, the undersigned, certify that the information in this Declaration of Candidacy for Retention, required by AS 15.35.055,
15.35.057, is true and complete, and that I meet the specific requirements of this office. I also acknowledge that should I
choose to withdraw my candidacy, my withdrawal must be received by the Director of Elections in writing over my
signature at least 64 days before the election.
Subscribed and sworn to before me this
_______________________________________________________
(Candidate’s Signature)
day of
_______
____________________, 20____.
________________________________________
____________________________ _________________________
(Signature of Notary Public)
(Primary Phone)
(Alternate Phone)
My commission expires: _________________
To assist staff in verifying candidate/voter identification,
please provide one of the following:
(SSN, ADL, Voter # or DOB) ___________________________
NOTARY SEAL
Privacy Disclaimer
Unless otherwise made confidential or protected from disclosure by law, information provided on this form may be subject to disclosure
under the Alaska Public Records Act (AS 40.25.100—40.25.295). Failure to provide requested personal information may result in the
Division’s inability to process relevant portions of this form. Requested information will be used only for purposes directly associated
with the processing of this form. For information on how to challenge the accuracy or completeness of personal information maintained
by the Division, please send the Division a written request that the personal information be changed. The request must comply with AS
40.25.310 and be sent to the Division of Elections at the following address: Division of Elections, Director’s Office, PO Box 110017,
Juneau, AK 99811-0017.
A27 (Rev 01/05/2017)
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