HomeMy WebLinkAboutApplication for Place on the Ballot 02.12.2026 Kipp, Emily Kaye2-26
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
09/2021
APPLICATION FOR A PLACE ON THE BALLOT FOR A GENERAL ELECTION
FOR A CITY, SCHOOL DISTRICT OR OTHER POLITICAL SUBDIVISION
ALL INFORMATION IS REQUIRED TO BE PROVIDED UNLESS INDICATED AS OPTIONAL' Failure to provide required information may result in reiection of application.
APPLICATION FOR A PLACE ON THE V\I\ Q— , rd GENERAL ELECTION BALLOT
TO: City Secretary/Secretary of Board tharne of lection)
1 request that my name be placed on the above -named official ballot as a candidate for the office indicated below. _
O��FVVFI��CE SOUGHT (Include any place umber or otherdistinguishing number, if any.) INDICATE TERM
&' ' �`R � `� F— FULL O UNEXPIRED
FULL NA (First, Middle, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THEBALLOT*
// II
PERMANENT RE ENCE AR S5 (Do not i lud a P.O. Box or Rural ute, if
PUBLIC MAILING ADD SS (Optional) IA dress for which y6u re eive
you
STATE
ZIP
CITY
CITY
STATE
ZIP
� .
g �
PLYBLIC EMAIL ADDRESS (Optional) (Address for OCCUPATION (Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID
h'
O E CONTACT INFFORMATN (Optionala
h
Home: I '�— �
FELONY CONVICTION STATUS (You MUST check one)
LENGTH OF CONTINUOUS RESIDENCE
AS OF DATE THIS APPLICATION WAS SWORN
E>Kave not been finally convicted of a felony.
IN TERRITORY/DISTRICT/PRECINCT FROM
IN THE STATE OF TEXAS
❑ I have been finally convicted of a felony, but I have been
h
/✓Year(s)
WHICH THE OFFICE SQUGHT IS ELECTED
�—year(s)
pardoned or otherwise released from the resulting
disabilities of that felony conviction and I have provided
month(s)
month(s)
proof of this fact with the submission of this application.3
*If using a nickname as part of your name to appear on the ballot, you are also signing and swearing to the following statements: I further 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. _t i
1 —L/,i
Before me, the undersigned authority, on this day personally appeared (name of candidate }E'�/l A.�r1 f2 t who
being by me here and now duly sworn, u an oath says: � tiL ' ,
"I, (name of candidate � ( County, Texas,
being a candidate for the office of r hat I ill support and defend the Constitution and
laws of the United States and of the Me of Texas. I anVa citizen of the United 5 ates eligible 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 things true and correct."
SIGNATURE Of CANDI RATE
Sworn to and subscribed before me this the /^-rrl'-day of 62. (, by k�WL Cwnp —Wr4 k
(day) (month) (year) J (na(illne of candidate)
el
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Signature of O icer Authorized to Administer Oath4 Printed Na a of Officer Authorized to Administer Oath
Title of Officer Authorized to Adrn�pister Oath
TO BE COMPLETED BY FILING OFFICER: THIS APPLICATION IS ACCOMPANIED BY THE REQUIRED FILING FEE (if Applicable) PAID BY:
❑ CASH ❑ CHECK ❑ MONEY ORDER ❑ CASHIERS CHECK OR ❑ PETITION IN LIEU OF A FILING FEE
8
This document and $ 6 filing fee or a nominating petition of pages received. Voter Registration Status Verified
2
0-2- / I �'-- / a z / 1-Z / 2076 (See Section 2.007)
Date Received Date Accepted Signature of dima Officer or