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To: The Chairman and Secretary of the County Executive Committee of the _ Party of County/Municipality State of Georgia DECLARATION OF CANDIDACY AND AFFIDAVIT (COUNTY/MUNICIPALITY) I, the undersigned, being first duly sworn on oath, do depose and say: my name is _ ; my residence address is (Street Number) (Street) ; (City) (County) (State) (Zip Code) my post office address is ; my telephone number is ; (Business) (Home) my profession, business, occupation (if any) is ; the name of my precinct is ; I am an elector of the county of my residence and eligible to vote in the primary election in which I am a candidate for nomination; the name of the office I am seeking is ; my date of birth is ; (Circuit, District, or Post if Applicable) I have been a legal resident of the State of Georgia consecutive years; I have been a legal resident of _ county for consecutive years; I have been a legal resident of my district (if applicable) for consecutive years; I have been a legal resident of my circuit (if applicable) for consecutive years; I am a citizen of the United States; I am eligible to hold such office; I am a candidate for nomination in the _ to be held on the _ day of ,20 ; (Primary) I have never been convicted and sentenced in any court of competent jurisdiction for fraudulent violation of primary or election laws, malfeasance in office, or felony involving moral turpitude or conviction of domestic violence under the laws of this State, any other State, or of the United States, or, if so convicted that my civil rights have been restored; and at least ten years have elapsed from the date of the completion of the sentence without a subsequent conviction of another felony involving moral turpitude; I am not a defaulter for any federal, state, county, municipal, or school system taxes required of such officeholder or candidate if such person has been finally adjudicated by a court of competent jurisdiction to owe those taxes, but such ineligibility may be removed at any time by full payment thereof, or by making payments to the tax authority pursuant to a payment plan, or under such other conditions as the General Assembly may provide by general law (pursuant to Ga. Const. Art. II, Sec. II, paragraph III); I will not knowingly violate any provisions of the Georgia Election Code (O.C.G.A. § 21-2) or of the rules or regulations adopted thereunder; I will not knowingly violate the rules or regulations of the party. I understand that any false statement knowingly made by me in this Declaration of Candidacy and Affidavit will subject me to criminal penalties as provided by law and I hereby request you to cause my name to be placed on the ballots to be used in such primary election as a candidate for the nomination I am seeking. _ (Signature of Candidate) Sworn to and subscribed before this day of , _ . _ (Notary Public) My Commission Expires: (Required by Ga. Election Code O.C.G.A. § 21.2.153.) I desire that my name appear on the ballot as follows Should I be elected, I desire that my name appear on official (the surname of the candidate shall be as it appears documents as follows: on the candidate’s voter registration card): _ (Please Print) (Please Print) (over) SIGN ---PAGE BREAK--- 1. [ ] I hereby tender check/cash in the amount of $ NAME OF BANK: CHECK NUMBER:_ In the event that a candidate pays his or her qualifying fee with a check that is subsequently returned for insufficient funds, the superintendent shall automatically find that such candidate has not met the qualifications for holding the office being sought, unless the bank, credit union, or other financial institution returning the check certifies in writing by an officer's or director's oath that the bank, credit union, or financial institution erred in returning the check as prescribed in O.C.G.A. §21-2-6(d). [ ] I hereby file a Pauper’s Affidavit, accompanied by a qualifying petition as prescribed in O.C.G.A. § 21-2-153 in lieu of paying the qualifying fee. NOTE: CANDIDATES FOR THE FOLLOWING OFFICES MUST FILE AN ADDITIONAL AFFIDAVIT IN ACCORDANCE WITH THE LISTED CODE SECTION AND MAY HAVE OTHER REQUIREMENTS IN ORDER TO BE QUALIFIED TO SEEK OFFICE. CANDIDATES SHOULD REVIEW THE QUALIFICATIONS FOR WHICH THEY OFFER FOR ELECTION CAREFULLY. CLERK OF SUPERIOR COURT O.C.G.A. § 15-6-50(b)(2) JUDGE OF THE PROBATE COURT O.C.G.A. § 15-9-2(a)(2) SHERIFF O.C.G.A. § 15-16-1(c)(2) CORONER O.C.G.A. § 45-16-1(b)(2) TAX RECEIVER O.C.G.A. § 48-5-210(b)(2) TAX COLLECTOR O.C.G.A. § 48-5-210(b)(2) TAX COMMISSIONER O.C.G.A. § 48-5-210(b)(2) Form DC-C&M-09