Date of General Election:

Name

Home Address:

City, State and Zip Code:

Date of Birth:

Telephone: Optional.

E-mail Address: Optional.

Organization name: (if applicable)

I swear or affirm that the information I have provided above is correct. I fully intend to be a candidate of the political organization stated above (if applicable) and to meet the filing requirements of the office for which I intend to run. I will not appear on the Primary Election ballot for the General Election in which I plan to run for office. I am eligible to hold the office for which I will be a candidate; if I am elected I will qualify by taking the oath of office. I know that I cannot hold a public office if I have been convicted of a felony or other infamous crime and my rights have not been restored by the governor or by the president of the United States.

I will file my affidavit of candidacy and nomination papers as required by Chapter 44 or Chapter 45 of the Code of Iowa. I am aware that the affidavit of candidacy and nomination papers may not be filed earlier than 92 days nor later than 5 p.m. 69 days before the General Election (Code of Iowa, 44.4, 45.4).

I recognize that this form is a public document and that the information it contains will be made available to the public and may be published and placed on the internet.

Signed: ______________________________ Date: ______________