Form SFN 10172 Statement of Interests - North Dakota

Form SFN10172 or the "Statement Of Interests" is a form issued by the North Dakota Secretary of State.

Download a fillable PDF version of the Form SFN10172 down below or find it on the North Dakota Secretary of State Forms website.

ADVERTISEMENT
COMPLETE, PRINT, SIGN AND MAIL
Secretary of State
STATEMENT OF INTERESTS
State of North Dakota
600 E Boulevard Ave Dept 108
SECRETARY OF STATE
Bismarck ND 58505-0500
SFN 10172 (10-2015)
Telephone: (701) 328-4146
Toll-Free: (800) 352-0867, option 6
Fax: (701) 328-3413
SEE PAGE 4 FOR INSTRUCTIONS
Email: soselect@nd.gov
Website: Vote.ND.Gov
References to the Statement of Interests are found in North Dakota Century Code, Chapter 16.1-09.
FILING REQUIREMENTS FOR STATEMENT OF INTERESTS
1.
Every candidate for elective office shall file a Statement of Interests with the appropriate filing officer with whom the candidate filed his/her
Certificate of Endorsement SFN 17196 or Petition/Certificate of Nomination SFN 2704.
a.
Candidates for President and Vice President of the United States shall file with the Secretary of State either a Statement of Interests as
required by Chapter 16.1-09 of the North Dakota Century Code or a copy of the personal disclosure statement required by the Federal
Election Commission.
b.
Candidates for US Senate and US House of Representatives shall file this form with the Secretary of State or a copy of the personal
disclosure statement required by the Federal Election Commission.
c.
Candidates for statewide office shall file with the Secretary of State.
d.
Candidates for legislative office shall file with the Secretary of State.
e.
Candidates for Garrison Conservancy and Soil Conservation district shall file with the County Auditor in their county of residence.
f.
Candidates for District Judge shall file with the Secretary of State.
g.
Candidates for county offices shall file with the County Auditor.
h.
Candidates for city offices shall file with the City Auditor.
i.
Candidates for school district offices shall file with the School Business Manager of the school district.
The Statement of Interests shall be filed at the same time a Petition/Certificate of Nomination or Certificate of Endorsement is filed.
Candidates filing a Statement of Interests for the primary election need not re-file for the general election.
Every person appointed by the Governor to a state agency, board, bureau, commission, department, or occupation or professional licensing
2.
board shall file a Statement of Interests with the Secretary of State no later than the announcement of the appointment.
Please refer to the instructions provided on page 4 of the Statement of Interest for answering specific questions before completing this form.
Please Print
Name of Candidate or Appointee
Telephone Number
Spouse's Name
Address
City
State
Zip Code
Office Which Candidate is Seeking
Position to Which Appointed
OR
ITEM A
Name of Business or Employer
PRINCIPAL OCCUPATION/SOURCE OF INCOME (Check One)
Farmer
Military
Investor or Retired
Clerical and Sales
Government Employee
Business Owner
Laborer
Professional
Craftsman
Student
Other
Spouse's Name of Business or Employer
SPOUSE'S PRINCIPAL OCCUPATION/SOURCE OF INCOME (Check One)
Farmer
Military
Investor or Retired
Clerical and Sales
Government Employee
Business Owner
Laborer
Professional
Craftsman
Student
Other
COMPLETE, PRINT, SIGN AND MAIL
Secretary of State
STATEMENT OF INTERESTS
State of North Dakota
600 E Boulevard Ave Dept 108
SECRETARY OF STATE
Bismarck ND 58505-0500
SFN 10172 (10-2015)
Telephone: (701) 328-4146
Toll-Free: (800) 352-0867, option 6
Fax: (701) 328-3413
SEE PAGE 4 FOR INSTRUCTIONS
Email: soselect@nd.gov
Website: Vote.ND.Gov
References to the Statement of Interests are found in North Dakota Century Code, Chapter 16.1-09.
FILING REQUIREMENTS FOR STATEMENT OF INTERESTS
1.
Every candidate for elective office shall file a Statement of Interests with the appropriate filing officer with whom the candidate filed his/her
Certificate of Endorsement SFN 17196 or Petition/Certificate of Nomination SFN 2704.
a.
Candidates for President and Vice President of the United States shall file with the Secretary of State either a Statement of Interests as
required by Chapter 16.1-09 of the North Dakota Century Code or a copy of the personal disclosure statement required by the Federal
Election Commission.
b.
Candidates for US Senate and US House of Representatives shall file this form with the Secretary of State or a copy of the personal
disclosure statement required by the Federal Election Commission.
c.
Candidates for statewide office shall file with the Secretary of State.
d.
Candidates for legislative office shall file with the Secretary of State.
e.
Candidates for Garrison Conservancy and Soil Conservation district shall file with the County Auditor in their county of residence.
f.
Candidates for District Judge shall file with the Secretary of State.
g.
Candidates for county offices shall file with the County Auditor.
h.
Candidates for city offices shall file with the City Auditor.
i.
Candidates for school district offices shall file with the School Business Manager of the school district.
The Statement of Interests shall be filed at the same time a Petition/Certificate of Nomination or Certificate of Endorsement is filed.
Candidates filing a Statement of Interests for the primary election need not re-file for the general election.
Every person appointed by the Governor to a state agency, board, bureau, commission, department, or occupation or professional licensing
2.
board shall file a Statement of Interests with the Secretary of State no later than the announcement of the appointment.
Please refer to the instructions provided on page 4 of the Statement of Interest for answering specific questions before completing this form.
Please Print
Name of Candidate or Appointee
Telephone Number
Spouse's Name
Address
City
State
Zip Code
Office Which Candidate is Seeking
Position to Which Appointed
OR
ITEM A
Name of Business or Employer
PRINCIPAL OCCUPATION/SOURCE OF INCOME (Check One)
Farmer
Military
Investor or Retired
Clerical and Sales
Government Employee
Business Owner
Laborer
Professional
Craftsman
Student
Other
Spouse's Name of Business or Employer
SPOUSE'S PRINCIPAL OCCUPATION/SOURCE OF INCOME (Check One)
Farmer
Military
Investor or Retired
Clerical and Sales
Government Employee
Business Owner
Laborer
Professional
Craftsman
Student
Other
SFN 10172 (10-2015)
Page 2 of 4
Please Print
ITEM B
List the name of each business or trust that is NOT the principal source of income in which you and/or your spouse have a
financial interest.
[BUSINESS NAME OR TRUST NAME (list city and state where located)]
SELF
SPOUSE
X
X
EXAMPLE: Make Me A Lot of Money Investment Co. (Mutual Funds) Bismarck, ND
ITEM C
Place an "X" to
List below the associations or institutions with which you and/or your spouse are closely associated,
or serve as a director or officer, AND which may be affected by legislative action (for legislative
indicate the
interested party.
candidates), or action of the officeholder of the office to which you are a candidate or appointee.
ASSOCIATION OR INSTITUTION
CAPACITY
SELF
SPOUSE
SFN 10172 (10-2015)
Page 3 of 4
Please Print
ITEM D
Place an "X" to
Identify below by name, any business offices, business directorships, and fiduciary relationships that
indicate the
you and/or your spouse have held in the preceding year.
interested party.
ASSOCIATION OR INSTITUTION
CAPACITY
SELF
SPOUSE
AFFIDAVIT
I, the undersigned, declare this Statement of Interests has been examined by me and to the best of my knowledge is a true,
correct, and complete statement of my financial interests. I understand any intentional violation of the law requiring the filing of
this statement shall result in my being deprived of my appointment or assuming the duties of the elective office.
Signature of Candidate or Appointee
Date
SFN 10172 (10-2015)
Page 4 of 4
INSTRUCTIONS FOR STATEMENT OF INTERESTS
WHO FILES: The Statement of Interests must be filed by all candidates seeking to have their name placed on the ballot for federal, statewide,
judicial district, legislative, county, multi-district, city, and school district office. Every person appointed by the Governor to a state agency,
board, bureau, commission, department, or occupation or professional licensing board shall also file a Statement of Interests.
WHEN TO FILE: Every candidate for elective office must file a Statement of Interests with the appropriate filing officer at the same time as filing
his/her Certificate of Endorsement SFN 17196 or Petition/Certificate of Nomination SFN 2704 and Affidavit of Candidacy SFN 2703.
Appointees of the Governor shall file a Statement of Interests no later than the announcement of the appointment.
WHERE TO FILE:
FEDERAL, STATEWIDE, JUDICIAL, AND LEGISLATIVE DISTRICT CANDIDATES - File with the Secretary of State:
Secretary of State
State of North Dakota
600 E Boulevard Ave Dept 108
Bismarck ND 58505-0500
APPOINTEES OF THE GOVERNOR - File with the Secretary of State
COUNTY AND MULTI-DISTRICT CANDIDATES - File with the County Auditor in their county of residence
CITY CANDIDATES - File with the City Auditor
SCHOOL DISTRICT CANDIDATES - File with the School Business Manager
HOW TO FILE:
ITEM A - PRINCIPAL OCCUPATION: The occupations listed are those defined on the North Dakota state income tax return. Check only one
category for the principal source of income for yourself, and only one for your spouse. Please mark and complete the box labeled "Other" if you
or your spouse's occupation is not listed.
ITEM B - List by name each business or trust that is NOT the principal source of income, in which you and/or your spouse have a financial
interest. Include any of the following that apply:
1.
Any business or trust in which you and/or your spouse own a legal or equitable interest.
2.
Any business or trust in which you and/or your spouse have investments. Include the name of the business or trust of which you have
stocks, mutual funds, bonds, debentures, or debt obligations of corporations and/or municipal corporations. Financial interests that are
contained in diversified portfolios need only be mentioned by the brokerage establishment it is with.
3.
Any business or trust from which you and/or your spouse receive compensation.
4.
Any business or trust paying you and/or your spouse a fee or commission for professional or consulting services. Include those public
agencies from which you and/or your spouse received a fee or commission. Attorneys and others who list their principal occupation as
"professional" are not required to list clients.
5.
Public agencies (state or local) to which you and/or your spouse sold goods or services.
ITEM C - List the associations or institutions with which you and/or your spouse are closely associated, or serve as a director or officer of,
and which maybe affected by legislative action (for legislative candidates) or action of the officeholder of the office to which you are a candidate
or appointee.
List organizations and associations and note the capacity of you and/or your spouse's relationship such as "member", "board of
directors", "consultant", etc.
ITEM D - Identify by name any business office, business directorship, and fiduciary relationship that you and/or your spouse have held in
the preceding calendar year.
Fiduciary means acting as a guardian, trustee, executor, administrator, or conservator for any person, whether individual or corporate.
Specify the capacity of the relationship of you and/or your spouse for any of the listed businesses, trusts and/or fiduciary relationships,
such as "director", "executor", "trustee", etc.
SPECIAL NOTES:
Items B, C and D of this form have limited space for listing items. If you need more space, attach additional sheets in the same format
and clearly identify which of the three items (B, C or D) the additional sheet continues. Insert the additional sheets into this form.
Use an "X" to indicate the "interest" relationship for (a) yourself, or (b) your spouse.
You are not required to list dollar amounts or the nature of the work performed in ITEMS B, C or D.
ASSISTANCE: Questions regarding the Statement of Interests may be directed to the Elections Unit of the Secretary of State's Office at (701)
328-4146 or (800) 352-0867 or the appropriate filing officer.

Download Form SFN 10172 Statement of Interests - North Dakota

653 times
Rate
4.8(4.8 / 5) 39 votes
ADVERTISEMENT
Page of 4