State Of Louisiana - Notice Of Candidacy
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1STATE OF LOUISIANA - NOTICE OF CANDIDACY (Qualifying Form)
This Notice of Candidacy must be executed before a notary public OR witnessed by two persons who are registered to vote on the office the candidate seeks.
If the candidate is serving outside the state with the armed forces of the United States, the Notice of Candidacy shall be witnessed by a commissioned officer
in the armed forces of the United States. This Notice of Candidacy must be filed with the appropriate qualifying official. If this Notice of Candidacy is being
filed by an agent on behalf of the candidate, the Agent Affidavit required by R.S. 18:463(A)(1)(c) shall also be filed with the qualifying official.
(Name):
(Domicile address):
(Mailing address, if different):
Statistical Information(OPTIONAL)
(Telephone - include area code):
Race:
W=White B=Black O=Other
I am the incumbent:
Y=Yes, N=No
M=Male F=Female
Sex:
I HEREBY CERTIFY THAT:
1. I will be a candidate in the Primary Election to be held on
for election to the office of
(Failure to follow these instructions may result in your being disqualified as a candidate)
INSTRUCTIONS FOR LINE 2:
R.S. 18:463 provides that you may designate your given, first and middle name, the initial of your given, first and middle name, a
nickname, or any combination thereof, but you cannot designate a deceptive name. You cannot designate a title or an occupation or
professional description or abbreviation. If your nickname is included, it must be set off with quotation marks and must be placed
immediately preceding your last name (surname). You must include your last name (surname) in your designation.
2. I designate that my name be printed on the ballot as follows: (titles will not be printed on the ballot)
Suffix:
First:
Last:
3. I attach:
______ Cash
Total Amount Received:
(choose one)
______ Certified or cashier's check on a state or national bank or credit union
$
______ U.S. Postal money order
______ Money order issued by a state or national bank or credit union
______ Nominating petition OR _____ U.S. armed forces stationed/deployed outside the U.S.
4.
I am a duly qualified elector of the following:
Parish:
Ward/Dist:
Precinct:
My party affiliation is:
5.
(Specify party name if affiliated with a recognized political party, "other" if affiliated with a political party that is not a recognized
political party or no party if not affiliated with any political party.)
6. I have read this Notice of Candidacy and I meet the qualifications of the office for which I am qualifying.
7.
I am not currently under an order of imprisonment for conviction of a felony and I am not prohibited from qualifying as a candidate
for conviction of a felony pursuant to Article I, Section 10 of the Constitution of Louisiana.
8. If I am a candidate for any office other than United States senator or representative in congress, that for each of the previous five tax
years, I have filed my federal and state income tax returns, have filed for an extension of time for filing either my federal or state
income tax return or both, or was not required to file either a federal or state income tax return or both.
9. I acknowledge that I am subject to the provisions of the Campaign Finance Disclosure Act if I am a candidate for any office other than
United States senator, representative in congress, or member of a committee of a political party and that I do not owe any
outstanding fines, fees, or penalties pursuant to the Campaign Finance Disclosure Act.
10. If I am a candidate for a major or district office as defined in R.S. 18:1483, I have filed each report that I have been required to file by
the Campaign Finance Disclosure Act, if any were previously due.
11.
I do not owe any outstanding fines, fees, or penalties pursuant to the Code of Governmental Ethics.
12.
I certify that I am knowledgeable of the laws governing election offenses as provided in Chapter 10 of Title 18 and the
prohibitions relative to erecting, displaying, or posting political campaign signs on any highway right-of-way, publicly owned
property or right-of-way, or to or on any public utility pole or stanchion, as provided in R.S. 48:347(D), 30:2544(A), and 18:1470.
13.
All the statements contained herein are true and correct.
Signature of Candidate:
X
WITNESSES:
Sworn to and subscribed before me, Notary Public, this
day of
,
Notary Public
Printed name and number
NOTICE: Copies of the Agent Affidavit required by R.S. 18:463(A)(1)(c) are available from the Clerk of Court or the Secretary of
State. Copies of the forms and pamphlets of explanation and instruction which are distributed by the Supervisory Committee on
Campaign Finance Disclosure are available from the Clerk of Court or the Committee; and the information contained in this notice of
candidacy may be posted on the website of the Secretary of State, at his discretion.
RECEIVED $
qualifying fee and $
additional fee, OR
no fee on this
day of
at
o'clock
M
,
Signature of Officer
Title of Officer
Prepared and furnished by Secretary of State
Approved by Attorney General
QF-42(Rev. 12/2012)
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