Full Packet - 2012-13 District Elections - City of Champaign

10 ILCS 5/10-5, 10-5.1 ATTACH TO PETITION SuggestedFidlar Election Co., Rock Island, Illinois PE-3 Revised July, 2007SBE No. P-1ASTATEMENT OF CANDIDACYNONPARTISANNAME ADDRESS-ZIP CODE OFFICE CITY OR DISTRICTMickey J. Mouse100 N. Neil St.Champaign, IL61820City of ChampaignCity Council MemberDistrict - *Insert theDistrict Number hereCity of Champaign,IllinoisIf required pursuant to 10 ILCS 5/10-5.1, Complete the following (this information will appear on the ballot) FORMERLY KNOWNAs _Mortimer_______________________________________________ UNTIL NAME CHANGED ON _9/2006__________________.(list all names during last 3 years)(list date of each name change)STATE OF ILLINOIS )) SS.County of __Champaign__________)I, _Mickey J. Mouse________________________ being first duly sworn (or affirmed), say that I reside at__100 N. Neil St.________________________, in the City, Village, Unincorporated Area (circle one) of_Champaign____ (if unincorporated, list municipality that provides postal service) Zip Code 61820, in theCounty of Champaign, State of Illinois; that I am a qualified voter therein, that I am a candidate forCity of Champaign - CityNomination/Election to the office of Council Member District * in the City of Champaign to be votedName of City, Village or Special Districtupon at the election to be held on February 26, 2013 (date of election) and that I am legally qualified to holdsuch office and that I have filed (or I will file before the close of the petition filing period) a Statement ofEconomic Interests as required by the Illinois Governmental Ethics Act and I hereby request that my namebe printed upon the official ballot for Nomination/Election to such office.____________________________________(Signature of Candidate)Signed and sworn to (or affirmed) by Mickey J. Mouse before me, on 09/25/2012.(Name of Candidate) (insert month, day, year)(SEAL)_____________________________________(Notary Public’s Signature)