Download Nomination Petitions - IMPORTANT NOTICE

Download Nomination Petitions - IMPORTANT NOTICE Nomination petitions must be printed as duplex (two-sided, front and back) on plain white 8 1/2" x 11" (letter-size) paper. This requirement cannot be satisfied by printing each side of the duplex nomination petition on a separate sheet of 8 1/2" x 11" paper and affixing the two sheets together. THE NOMINATION PETITION FORMS ATTACHED ARE BEING PROVIDED FOR THE PURPOSE OF SUPPLEMENTING THE SUPPLY OF NOMINATION PETITIONS THAT YOU RECEIVED FROM THE BUCKS COUNTY BOARD OF ELECTIONS. THESE FORMS ARE FOR CANDIDATES OF THE REPUBLICAN PARTY AND THE DEMOCRATIC PARTY ONLY. CANDIDATES OF MINOR POLITICAL PARTIES AND POLITICAL BODIES MAY NOT UTILIZE THESE FORMS. BEFORE DOWNLOADING OR PRINTING ANY OF THE NOMINATION PETITIONS ON THIS PAGE, PLEASE READ THE FOLLOWING INSTRUCTIONS VERY CAREFULLY. FAILURE TO REPRODUCE THE NOMINATION PETITIONS CORRECTLY MAY RESULT IN THE REJECTION OF THOSE FORMS. 1. All highlighted fields must be completed - type on-screen and print as noted in section 2. 2. Nomination petitions must be printed as duplex (two-sided, front and back) on plain white 8 1/2" x 11" (letter size) paper. This requirement cannot be satisfied by printing each side of the duplex nomination petition on a separate sheet of 8 1/2" x 11" paper and affixing the two sheets together. 3. Please read all instructions provided with the nomination petitions prior to circulation. IF YOU HAVE ANY QUESTIONS OR ARE UNSURE WHETHER YOU HAVE CORRECTLY REPRODUCED ANY OF THE FORMS ON THIS PAGE, PLEASE CONTACT THE BUCKS COUNTY BOARD OF ELECTIONS AT 215-348-6154. The forms below cannot be altered. Any alteration to the forms may invalidate them. IF YOU WOULD LIKE A RECEIPT FOR YOUR NOMINATION PETITION, PLEASE BRING THIS COMPLETED FORM WITH YOU WHEN YOU FILE. THANK YOU. Name: Office: District: Filing Fee (if applicable): 01-01-17

PLEASE BE SURE TO PRINT THE NEXT TWO PAGES (# s 3 and 4 of packet) DOUBLE-SIDED on LETTER-SIZE PAPER YOUR NOMINATION PETITIONS WILL NOT BE ACCEPTED IF PRINTED SINGLE-SIDED PLEASE CALL OUR OFFICE IF YOU HAVE ANY QUESTIONS

PETITION - COUNTY OFFICE and MAGISTERIAL DISTRICT JUDGE - 2017 PAGE of Signatures must be procured within the legal period for securing same; and this Petition must be filed in the office of the County Board of Elections on or before the last day prescribed by law. EACH SIGNER MAY SIGN PETITIONS FOR AS MANY CANDIDATES FOR EACH OFFICE AS HE CAN VOTE FOR, AND NO MORE. COMMONWEALTH OF PENNSYLVANIA PETITION To have name of Candidate printed upon the Official Ballot for the Municipal Primary We, the undersigned, all of whom are qualified electors of County and of, and are registered and enrolled members of the Party or Policy, hereby petition the County Board of Elections of County to have the name of (TYPEWRITE, PRINT OR WRITE PLAINLY THE ABOVE NAME AS YOU WISH IT TO APPEAR ON THE OFFICIAL BALLOT) Profession, Business or Occupation is (ELECTORAL DISTRICT IN WHICH THE NOMINATION OR ELECTION IS TO BE MADE) of Residence is, be printed upon the Official Ballot of the Aforesaid Party in the said District, for the Municipal Primary for the year, as a candidate for the Office of: for a year term. (TITLE OF OFFICE) (WITH STREET, NUMBER (WHERE POSSIBLE) AND ZIP CODE), whose, Place SIGNERS ARE CAUTIONED TO AVOID THE USE OF DITTO MARKS PRINTED NAME PLACE OF RESIDENCE SIGNATURE OF ELECTOR OF ELECTOR HOUSE NO. STREET or ROAD MUNICIPALITY for office use only please DATE OF SIGNING 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

SIGNATURE OF ELECTOR PRINTED NAME OF ELECTOR PLACE OF RESIDENCE HOUSE NO. STREET or ROAD MUNICIPALITY DATE OF SIGNING 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 AFFIDAVIT OF CIRCULATOR COMMONWEALTH OF PENNSYLVANIA COUNTY OF SS: Before me, the undersigned authority in and for said State and County, personally appeared the undersigned, who, being duly sworn according to law, did depose and say that he or she is a qualified elector duly registered and enrolled as a member of the political party referred to in this petition; that his or her residence is as set forth below; that the signers to the foregoing petition signed the same with full knowledge of the contents thereof; that their respective residences are correctly stated therein; that they all reside in the said political district; that each signed on the date set opposite his or her name; and that, to the best of the deponent's knowledge and belief, the signers are qualified, registered and enrolled members of the designated party of the aforesaid political district. (Underlined portion not applicable to Circulator for the office of Magisterial District Judge.) Sworn to and subscribed before me this day of, 20 NOTARY STAMP (SIGNATURE of CIRCULATOR) (PRINTED NAME of CIRCULATOR) (STREET ADDRESS, POST OFFICE and ZIP CODE of CIRCULATOR) (MUNICIPALITY of CIRCULATOR) (SIGNATURE of NOTARY) (TELEPHONE NUMBER and E-MAIL ADDRESS of CIRCULATOR)

COMMONWEALTH OF PENNSYLVANIA COUNTY OF BUCKS BUCKS COUNTY BOARD OF ELECTIONS CANDIDATE'S AFFIDAVIT SS: FOR OFFICE USE ONLY PLEASE Before me, the undersigned authority in and for said State and County, personally appeared the undersigned, who, being duly sworn according to law, did depose and say that his or her residence is as set forth below; that his or her election district is as set forth below; that the name of the office for which he or she consents to be a candidate is: (TITLE OF OFFICE, PARTY and LENGTH OF TERM) that he or she is eligible for said office; that he or she will not knowingly violate any election law, or any law regulating and limiting nomination and election expenses, and prohibiting corrupt practices in connection therewith; that he or she is aware of the provisions of Section 1626 of The Pennsylvania Election Code requiring pre-election and post-election reporting of campaign contributions and expenditures; and that he or she is not a candidate for an office which he or she already holds, the term of which is not set to expire in the same year as the office subject to the affidavit. Also that he or she is not a candidate for nomination for the same office of any political party other than the one designated in this petition. (Underlined portion not applicable to Candidates for the offices of School Director or Magisterial District Judge.) Any candidate for local office shall file a statement of financial interests for the preceding calendar year with the governing authority of the political subdivision in which he or she is a candidate on or before the last day for filing a petition to appear on the ballot for election. A COPY OF THE STATEMENT OF FINANCIAL INTERESTS SHALL ALSO BE APPENDED TO THIS PETITION. Sworn to and subscribed before me this day of, 20 NOTARY STAMP Signature of Candidate Party Office/District Printed Name of Candidate Street Address/Post Office/Zip Code (SIGNATURE of NOTARY) FILING FEES: Each person filing any nomination petition shall pay, for each petition at the time of filing, a filing fee, and no nomination petition shall be accepted or filed, unless and until such filing fee is paid by a certified check or money order or also by cash when filed with the county board. Whenever a petition is to be filed with the county board the person filing the same shall pay the filing fee in cash or by certified check or money order to the county board. All moneys, certified checks and money orders paid on account of filing fees shall be transmitted by the county board to the county treasurer and shall become part of the General Fund. Filing fees shall not be refunded for any cause whatsoever. No filing fee shall be paid for any public office for which no compensation is provided by law, nor for any public officer in any borough, town or township (of the second class) nor any party officer except as provided nor for any nomination petition for judge of election or inspector of elections. City/Borough/Township County Election District of Candidate (District Where Registered To Vote) Telephone Number Daytime Number E-mail Address

BUCKS COUNTY BOARD OF ELECTIONS WAIVER OF EXPENSE ACCOUNT REPORTING AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF BUCKS SS: Before me, the undersigned authority in and for said State and County, personally appeared the undersigned, who, being duly sworn according to law, did depose and say that as a candidate, he or she does not intend to form a political committee or to receive contributions or make expenditures in excess of Two Hundred Fifty Dollars ($250) during any reporting period, that, as a candidate, he or she will keep records of contributions and expenditures as required by law; that, as a candidate, he or she will file reports as required by law if contributions or expenditures exceed Two Hundred Fifty Dollars ($250). (Act No. 1980-127) Sworn to and subscribed before me this day of, 20 Signature of Candidate Party Office/District NOTARY STAMP Printed Name of Candidate Street Address/Post Office/Zip Code City/Borough/Township County (SIGNATURE of NOTARY) Election District of Candidate (District Where Registered To Vote) Telephone Number Daytime Number E-mail Address FOR OFFICE USE ONLY PLEASE

BUCKS COUNTY BOARD OF ELECTIONS INSTRUCTIONS FOR CIRCULATING NOMINATION PETITIONS FOR COUNTY AND MUNICIPAL OFFICES MUNICIPAL PRIMARY, MAY 16, 2017 - MUNICIPAL ELECTION, NOVEMBER 7, 2017 FIRST DAY TO CIRCULATE AND FILE NOMINATION PETITIONS------------------------FEBRUARY 14 LAST DAY TO CIRCULATE AND FILE NOMINATION PETITIONS-------------------------------MARCH 7 LAST DAY TO FILE OBJECTIONS TO NOMINATION PETITIONS-------------------------------MARCH 14 LAST DAY TO WITHDRAW AFTER FILING NOMINATION PETITIONS-----------------------MARCH 22 Candidates for Pennsylvania Judicial positions and for Judge of the Court of Common Pleas of Bucks County must request their petitions and instructions from the Bureau of Commissions, Elections and Legislation, 717-787-5280, www.dos.state.pa.us/bcel or RA-BCEL@pados.state.pa.us. ************************************************************************************************************************************************************************************ The Bucks County Board of Elections will supply nomination petitions, financial interest statements and campaign expense reporting forms for candidates for County Offices, Magisterial District Judge, School Director and Municipal Offices. 1. PRIOR TO CIRCULATION A. All blank spaces which appear at the top of the front page of each nomination page must be completed before signatures are obtained. B. Type or print the name of the candidate on the face of the petition exactly as the candidate wants it to appear on the ballot. Given names must be used. Titles such as Dr., Mr. or Mrs., etc. are not permitted. A nickname is allowed only if it is a derivative of the legal given name, unless an affidavit for primary ballot name change request is filed with our office. C. Check that the proper party, office title, municipality, ward and/or district (if applicable) and length of term is set forth in the petition. The Board of Elections does not make recommendations for length of term, if there is a choice. On School Director petitions, state the party, office title, school district, region (if applicable) and length of term. D. The offices of Judge of the Court of Common Pleas, Magisterial District Judge and School Director are the only candidates who are permitted to cross-file to run on both party tickets. E. The circulator may be the candidate or a qualified elector duly registered and enrolled as a member of the political party referred to in the petition (unless the petition relates to the nomination of a candidate for Magisterial District Judge, in which event the circulator need not be a duly registered and enrolled member of the designated party). F. The statutory requirement, 25 P.S. 2869, that requires the circulator of a nomination petition to be a resident of the relevant political district named in the petition will not be enforced pursuant to advice received from the Pennsylvania Office of the Attorney General in Villa v. Aichele, No. 13-cv-06374 (E.D. Pa. 2013). Please note that while the Bucks County Board of Elections will not reject nomination petitions on the basis that the circulator does not reside in the district specified in the nomination petition, candidates should be aware that their nomination petition may be challenged in the Court of Common Pleas on the basis that the circulator does not reside in the district. Bucks County Board of Elections 55 East Court Street Doylestown, Pennsylvania 18901 215-348-6154 The Bucks County Board of Elections does not mail nomination petitions. Please arrange to pick them up in our office beginning early February 2017. page 1 of 2

2. SIGNERS A. Each signer may sign petitions only for as many vacancies as there are for each office. B. Each signer of a petition must be a registered and enrolled elector of the political district and political party referred to in the petition. (Republican electors must sign Republican petitions; Democratic electors must sign Democratic petitions). C. Each signer must personally insert the information concerning signature and printed name, residence and date of signing, listing their address exactly as it appears on their voter registration record. The date of signing may be expressed in words or numbers, e.g. February 14, 2017 or 02/14/17. Given names must be used by signers. Titles such as Dr., Mr., Mrs. are not permitted. D. Ditto marks are not permitted. 3. AFFIDAVITS A. The affidavit of circulator on each petition page must be signed by the circulator and notarized after each page is circulated. B. The candidate s Affidavit and Loyalty Oath must be signed by the candidate and notarized. C. The Waiver of Expense Account Reporting Affidavit is to be signed by the candidate and notarized if he or she does not intend to form a political committee or receive contributions or make expenditures in excess of $250.00 during any reporting period. However, if the candidate either forms a political committee or collects or spends more than $250.00 during any reporting period, the waiver is invalid. If the waiver is not completed, the candidate will be required to file campaign expense reports at the scheduled filing dates. D. All applicable affidavits must be notarized. Each notarization must include the notary s signature and the notary s official inked stamp indicating the commission expiration date and municipality. 4. FILING A. All candidates must file a State Ethics Commission Statement of Financial Interest. Filing deadline for the original is the same date as filing deadline for nomination petitions. County Offices: Original is to be filed with the County Commissioner s Office. Magisterial District Judge: Original is to be filed with the County Commissioner s Office. School Director: Original is to be filed with the Secretary of the School District. Municipal Offices: Original is to be filed with the Secretary or Clerk of the Municipality. A copy of the financial interest statement must accompany the candidate s nomination petition when it is filed with the County Board of Elections. B. No nomination petition requiring a filing fee will be accepted for filing unless it is accompanied by the requisite fee. Filing fees for petitions filed with the county Board of Elections may be paid in cash, or by certified check or money order payable to Bucks County Treasurer. Note: filing fees are not refundable for any reason. C. The Pennsylvania Election Code requires that all petitions to be filed with the County Board of Elections must be received no later than the ordinary closing hour on the last day for filing - March 7, 2017. D. Petitions for Bucks County offices, Magisterial District Judge, School Director, Borough offices and Township offices must be filed in the office of the Bucks County Board of Elections no later than 5:00 p.m. on March 7, 2017. E. Petitions for the office of School Director in the North Penn and Souderton School Districts, and for Borough offices in Telford Borough, must be filed in Montgomery County. MPI 01-01-17 page 2 of 2

BUCKS COUNTY BOARD OF ELECTIONS - OFFICES FOR NOMINATION MUNICIPAL PRIMARY, MAY 16, 2017 - MUNICIPAL ELECTION, NOVEMBER 7, 2017 FIRST DAY TO CIRCULATE AND FILE NOMINATION PETITIONS-------------------------------FEBRUARY 14 LAST DAY TO CIRCULATE AND FILE NOMINATION PETITIONS-------------------------------------- MARCH 7 LAST DAY TO FILE OBJECTIONS TO NOMINATION PETITIONS--------------------------------------MARCH 14 LAST DAY TO WITHDRAW AFTER FILING NOMINATION PETITIONS------------------------------MARCH 22 PETITIONS FOR JUDICIAL OFFICES MUST BE OBTAINED FROM THE DEPARTMENT OF STATE, 210 NORTH OFFICE BUILDING, HARRISBURG, PA 17120. PLEASE DIRECT ALL INQUIRIES TO 717-787-5280, www.dos.state.pa.us/bcel or RA-BCEL@pados.state.pa.us. THE BUCKS COUNTY BOARD OF ELECTIONS DOES NOT HAVE THE AUTHORITY TO ANSWER QUESTIONS PERTAINING TO PETITIONS FOR JUDICIAL OFFICES. PETITIONS TO BE FILED IN THE OFFICE OF THE SECRETARY OF THE COMMONWEALTH IN HARRISBURG BY 5:00 P.M. ON MARCH 7, 2017 (LAST DAY TO FILE) JUDICIAL OFFICES TERM SIGNATURES FILING FEE SUPREME COURT SUPERIOR COURT COMMONWEALTH COURT COURT OF COMMON PLEAS 10 Years 10 Years 1000 (100 Signatures in each of at least 5 Counties) 250 $200.00 $100.00 PETITIONS TO BE FILED IN THE OFFICE OF THE BUCKS COUNTY BOARD OF ELECTIONS BY 5:00 P.M. ON MARCH 7, 2017 (LAST DAY TO FILE) COUNTY OFFICES DISTRICT ATTORNEY TERM 4 Years SIGNATURES 250 FILING FEE $100.00 SHERIFF 4 Years 250 $100.00 PROTHONOTARY 4 Years 250 $100.00 RECORDER OF DEEDS 4 Years 250 $100.00 CONTROLLER 4 Years 250 $100.00 MAGISTERIAL DISTRICT JUDGE 07-1-04, 07-1-06, 07-1-08, 6 Years 100 $50.00 07-1-09, 07-1-10, 07-1-12, 07-2-01, 07-2-03, 07-2-05, 07-3-03 SCHOOL DIRECTOR 2 or 4 Years 10 NONE BOROUGH OFFICES MAYOR 4 Years 10 NONE COUNCIL 2 or 4 Years 10 NONE TAX COLLECTOR 4 Years 10 NONE AUDITOR 2, 4 or 6 Years 10 NONE 1ST CLASS TOWNSHIP (BRISTOL) COUNCIL 4 Years 10 NONE BENSALEM TOWNSHIP MAYOR COUNCIL TREASURER 4 Years 4 Years 4 Years 10 10 10 NONE NONE NONE AUDITOR 6 Years 10 NONE 2ND CLASS TOWNSHIP SUPERVISOR 2, 4 or 6 Years 10 NONE TAX COLLECTOR 4 Years 10 NONE AUDITOR 2, 4 or 6 Years 10 NONE JUDGE OF ELECTIONS INSPECTOR OF ELECTIONS 4 Years 4 Years 10 5 NONE NONE NOTE: OFFICE INFORMATION SUBJECT TO CHANGE BEFORE FEBRUARY 14, 2017 MPO 01-01-17

www.ethics.pa.gov STATE ETHICS COMMISSION STATEMENT OF FINANCIAL INTERESTS THIS FORM IS CONSIDERED DEFICIENT IF ANY BLOCK IS NOT COMPLETED OR IF SIGNATURE OR DATE IS MISSING. SIGN THE FORM USING THE CURRENT DATE. DO NOT BACK DATE SIGNATURE. THOSE INDIVIDUALS WHO HOLD MORE THAN ONE OFFICE AND/OR POSITION MUST FILE A COPY OF THEIR FORM AT EACH FILING LOCATION. FILERS MAY USE THE ONLINE FILING SYSTEM AT THE STATE ETHICS COMMISSION'S WEBSITE: WWW.ETHICS.PA.GOV. A PAPER COPY MAY STILL BE REQUIRED TO BE SUBMITTED TO YOUR FILING LOCATION. FILERS SHOULD CHECK WITH THEIR FILING LOCATION FOR REQUIREMENTS. THIS FORM MUST BE COMPLETED AND FILED BY: A B C D A former public official or former public employee must file the year after termination of service with the governmental body. E IMPORTANT: review the filing chart (Page 4) for proper filing location. SEC-1 (Rev. 01/17)

STATEMENT OF FINANCIAL INTERESTS INSTRUCTIONS Please print neatly in capital letters. If you require more space than has been provided, please attach an 8 ½ X 11 piece of paper to the form. Blocks 01 through 06 are for current information. List a business, governmental and/or home address and daytime telephone number. Block 1 Please fill in your last name, first name, middle initial and suffix (if applicable) in the boxes provided. Public office candidates should use the exact name used on official nomination petition or papers. Block 2 List an office (business or governmental) or home address and daytime telephone number. Block 3 Please check the block or blocks to indicate your status. See definitions on page 1. If you are correcting a prior filing, please check the block, designating an amended form. Block 4 Please check the appropriate block (seeking, hold, held) for each position you list in the blocks below. List all of the public position(s) which you are seeking, currently hold, or have held in the prior calendar year. Please be sure to include job titles and official titles such as member or commissioner (even if serving as an alternate/designee). Block 5 Please list all political subdivision(s) agency(ies) as to which you: (1) are presently seeking a public position or public office as a candidate (incumbent or non-incumbent) or nominee; (2) presently hold a public position or public office; and/or (3) previously held a public position or public office during all or any portion of the calendar year listed in block 7. (The term political subdivision includes a county, city, borough, incorporated town, township, school district, vocational school, county institution, district, and any authority, entity or body organized by the aforementioned.) List the calendar year for which you are filing this form. For Example, if this form is being completed in the calendar year 2014, Block 6 block Please 07 list should your current read 2013 occupation and or all profession. information This in information blocks 08 may through have 15 already should been represent stated in block financial 4. interests for calendar year 2013. Block 7 List the calendar year for which you are filing this form. Like tax returns, these forms disclose financial information for a prior calendar year. For example, for the form due May 1, 2017, Block 7 would read "2016." The information in blocks 08 through 15 should represent financial interests for the calendar year listed. Block 8 REAL ESTATE INTERESTS: This block contains the address of any property which was involved in transactions (leasing, purchasing, or condemnation proceedings of real estate interests) with the Commonwealth or any other governmental body within the Commonwealth. If you have no direct or indirect interests in such a property, then check NONE. Block 9 CREDITORS: This block contains the name and address of any creditor and the interest rate of any debt over $6,500 regardless of whether such debt is held solely by you or jointly by you and any other individual, including your spouse, where each obligor is fully responsible for the obligation. A joint obligation with other persons, for which the filer is responsible only for a proportional share that is less than the reporting threshold, is not required to be reported. Do not report a mortgage or equity loan on your home (or secondary home), or loans or credit between you and your spouse, child, parent or sibling. Car loans, credit cards, personal loans and lines of credit must be listed on the form if the balance owed was in excess of $6,500 at any time during the calendar year. If you do not have any reportable creditor, then check NONE. Block 10 DIRECT OR INDIRECT SOURCES OF INCOME: List the name and address of each source of $1,300 or more of gross income regardless of whether such income is received solely by you or jointly by you and another individual such as a spouse. Income includes any money or thing of value received or to be received as a claim on future services or in recognition of services rendered in the past, whether in the form of a payment, fee, salary, expense, allowance, forbearance, forgiveness, interest, dividend, royalty, rent, capital gain, reward, severance payment, proceeds from the sale of a financial interest in a corporation, professional corporation, partnership or other entity resulting from termination/withdrawal therefrom upon assumption of public office or employment or any other form of recompense or combination thereof. The term refers to gross income; it includes prize winnings and tax-exempt income but does not include gifts, governmentally mandated payments or benefits, retirement, pension or annuity payments funded totally by contributions of the public official or employee, or miscellaneous, incidental income of minor dependent children. If you do not have ANY reportable source of income, then check NONE. Block 11 GIFTS: For each source of gift(s) valued at $250 or more in the aggregate, list the following information: the name and address of the source; the circumstances, including a description, of each gift; and the value of the gift(s). Do not report political contributions otherwise reportable as required by law, gift(s) from friends or family members (although the term friend does not include a registered lobbyist or employee of a registered lobbyist), or any commercially reasonable loan made in the ordinary course of business. If you did not receive any reportable gift, then check NONE. Block 12 TRANSPORTATION, LODGING, OR HOSPITALITY EXPENSES: List the name and address of each source and the amount of each TRANSPORTATION, payment/reimbursement LODGING, by the source OR for HOSPITALITY transportation, lodging EXPENSES: or hospitality List the that name you and received address in connection of each source with and your the public amount position of each if the payment/reimbursement aggregate amount of such by the payments/reimbursements source for transportation, by the lodging source or exceeds hospitality $650 that for you the calendar received year in connection for which you with are your reporting. public Do position not if the report aggregate reimbursements amount of made such payments/reimbursements by a governmental body or by by an the organization/association source exceeds $650 for of public the calendar officials/employees year for which of political you are subdivisions reporting. Do not that report you serve reimbursements in an official capacity. made by a If governmental you do not have body any reportable by an organization/association expense payments/reimbursements, of public then officials/employees check NONE. of political subdivisions that you serve in an official capacity. If you do not have any reportable expense payments/reimbursements, then check NONE. Block 13 OFFICE, DIRECTORSHIP OR EMPLOYMENT IN ANY BUSINESS ENTITY: List both the name and address of the business entity for any office that you hold (for example, President, Vice President, Secretary, Treasurer), any directorship that you hold (through service on a governing board such as a board of directors), and any employment that you have in any capacity whatsoever as to any business entity. This block focuses solely on your status as an officer, director or employee, regardless of income. If you do not have any office, directorship or employment in any business entity to report, then check NONE. Block 14 FINANCIAL INTERESTS: List the name and address and interest held in any business for profit of which you own more than 5% of the equity or more than 5% of the assets of economic interest in indebtedness. If you do not have any such financial interest to report, then check NONE. Block 15 TRANSFERRED BUSINESS INTERESTS: List the name and address of any business as to which you transferred a financial interest (as defined in Item 14) to a member of your immediate family (parent, spouse, child, brother or sister), as well as the interest held, relationship to the individual, and date of transfer. If you did not transfer any such business interest, then check NONE. Please sign the form and enter the current date. Do not back date your signature. SEC-1 (Rev. 01/17)

01/17 ADDRESS office (business or governmental) or home SEE INSTRUCTIONS. Information in Blocks 8-15 represents disclosure for the calendar year listed here: 2 0 DIRECT OR INDIRECT SOURCES OF INCOME including (but not limited to) all employment., (i.e., officer, director, employee, etc.) (i.e., 5%, 10%, etc.) THIS FORM IS CONSIDERED DEFICIENT IF ANY BLOCK ABOVE IS NOT COMPLETED. MAKE A COPY FOR YOUR RECORDS.

ORIGINAL COPY ADDITIONAL FILINGS * No additional copy required State Ethics Commission Incumbent Judges and Magisterial District Judges who are not candidates file a Statement of Financial Interests for Judicial Officers with the Administrative Office of Pennsylvania Courts (AOPC). Additional copy is not required to be filed (unless serving in multiple capacities, then file with each entity as required) No additional copy required Additional copy is not required to be filed (unless serving in multiple capacities, then file with each entity as required) * FILER IS RESPONSIBLE FOR MAKING ANY ADDITIONAL COPIES.

BUCKS COUNTY BOARD OF ELECTIONS CHECKLIST PRIOR TO FILING YOUR PETITION For: Candidates for County Office and Magisterial District Judge FRONT OF PETITION 1) Petition printing date must be 2017 or newer. 2) Candidate information - All descriptive information must be completed. 3) Signatures - A sufficient number of signatures is required. It is recommended that you obtain more than the minimum. 4) First date to obtain signatures cannot be earlier than February 14, 2017, and the last date to obtain signatures and file petitions is March 7, 2017. BACK OF PETITION 1) Affidavit of Circulator - must be signed and notarized after each page is circulated. NECESSARY ATTACHMENTS The Board of Elections cannot accept your petition without the following: 1) Candidate s Affidavit - must be completely filled out, signed and notarized with the Notary s current official inked rubber stamp. 2) You may or may not need to complete the Waiver of Expense Account Reporting Affidavit - please contact our office if you have questions. 3) Statement of Financial Interest - photocopy. Printing date on form must be 01/16 or newer. 4) Filing fee where applicable: cash, certified check or money order (no personal checks). IT IS THE CANDIDATE S RESPONSIBILITY TO INSURE THAT: 1) All signers are of the district and party named on the petition. 2) Circulator must be a member of the same political party as the candidate (except for Magisterial District Judge.) 3) Statement of Financial Interest - Original must be filed with the appropriate office. 1-1-17