HomeMy WebLinkAboutDelcaration of Write-In Candidacy-02.22.2022-Wilson-Kirby, JaquitaDocu$ign Envelope ID: F43EEBC3-A806-48A8 BA11-9DF4B330893E
2-28
Prescribed by Secretary of State
5ectlon 146.052, 146,053,146.054, Texas Election Code; Section 11.056, Texas Education Code; Section 49,101, Texas Water Code
09/2021
DECLARATION OF WRITE-IN CANDIDACY FOR CITIES, SCHOOL DISTRICTS AND OTHER POLITICAL SUBDIVISIONS
ALL INFORMATION IS REQUIRED TO BE PROVIDED UNLESS INDICATED AS OPTIONAL' Failure to provide required information may result in reiection of aoplica#ion.
DECLARATION OF WRITE-IN CANDIDACY FOR Georgetown Ci ty Counci
(Name of City, School District or Other Political Subdivision)
TO: Filing Officer
I declare that I am a write-in candidate for the office indicated below.
OFFICE SOUGHT (Include any place number or other distinguishing number, if any.)
INDICATE TERM
Georgetown City Council - District 7
® FULL ❑ UNEXPIRED
FULL NAME (First, Middle, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE LIST OF DECLARED
Jaqui to wi 1 son—Ki rby
WRITE-IN CANDIDATES"
i b
PERMANENT RESIDENCE ADDRESS (Do not include a P.O. Box or Rural Route. If
PUBLI&MAILING ADDRESS (Optional) (Addrest for which you receive
you do not have a residence address, describe location of residence.)
campaign related correspondence, if available.)
CITY STATE ZIP
CITY STATE ZIP
Georgetown TX 8626
Georgetown TX $627
PUBLIC EMAIL ADDRESS (Optional) (Address for
OCCUPATION (Do not leave blank)
DATE OF BIRTH VOTER REGISTRATION VUID
Facilitator
NUMBER2 (Optional)
0�/
CONTACT INFORMATION (Optional)
Home: 5128644 Cell:
FELONY CONVICTION STATUS (You MUST check one)
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE THIS APPLICATION WAS SWORN
I have not been finally convicted of a felony.
IN THE STATE OF TEXAS
IN TERRITORY/DISTRICT/PRECINCT FROM
❑ I have been finally convicted of a felony, but I have been
9
WHICH THE OFFICE SOUGHT IS ELECTED
pardoned or otherwise released from the resulting
year(s)
7 year(s)
disabilities of that felony conviction and I have provided
6
6
proof of this fact with the submission of this application 3
month(s)
month(s)
'elf using a nickname as part of your name to appear on the ballot, you are also signing and swearing to the following statements: I foirther swear that my
nickname does not constitute a slogan or contain a title, 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. Please review sections 52.031, 52.032 and 52.033 of the Texas Election Code regarding
the rules for how names may be listed on the official ballot.
Before me, the undersigned authority, on this day personally appeared (name of candidate)_J_aatl]_ta Wi I sQn—Ki rby _ _, who being by me
here and now duly sworn, upon oath says:
1, (name of candidate) 3 aqul to wi l son—Ki rby __Of Williamson County, Texas,
being a candidate for the office of _ Georgetown City _, swear that I will support and defend the Constitution and laws of the
United States and of the State of Texas. Pi ten of the United States ellgible to hold such office under the constitution and laws of this state. 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. I am aware that I must disclose any prior felony conviction, and if so
convicted, must provide proof that I have been pardoned or otherwise released from the resulting disabilities of any such final felony conviction. I am aware
that knowingly providing false information on the application regarding my possible felony conviction status constitutes a Class B misdemeanor. I further
swear that the foregoing statements included in my application are in all thi
Wt�SO�1��17
t!�tState
of Oklahoma
County of Lincoln SIGNATURE OF CANDIDATE
Sworn to and subscribed before me this the22nd day of February 2022 by JAQUITA WILSON KIRBY
— - ay - mvn - - y ) (name of candidate)
Pfje{r r� Patri6il Lviia J[Tne
1v��OtyRY
'� ' r •Patricia L ]Kill Jones
Signature of Officer Authorized t clA[j(tii t y 'Notary Public. State of Oklxhg4ihted N me of Officer Authorized to Administer Oath
A'�.,+,,r ��j ; L f�q� Conuoission Expires 07-01-2024
.ALL v![.AL Y Pad L.t1, • A— ' — ` o +
,
Titie of Officer Authorized to Ad inISL&■ 4,a' t)' ID �i IUii'�111
TO BE COMPLETED BY FILINGOFFICER:- THIS APPLICATION 15 ACCOMPANIED -BY THE It QUIRED FILIN�' FEE (If Applicable) PAID BY:
CASH ❑ CHECK ❑ MONEY ORDER. T0A I4A1dA8CRti G k6�I iC9� INIIIIEU OF A FILING FE�I
This document and $90 filing fee or a nominating petition of pages rec ived. Voter Registration Status Verified
(See Section 1.007) _
Date Received Date Accepted Signature f Fin—nVifficer or Designee