SELF-NOMINATION AND ACCEPTANCE FORM

PROPOSED CONIFER AREA PARK & RECREATION DISTRICT

I,
(full name of candidate as the name will appear on the ballot, cannot use titles such as “MD,” “Reverend,” of “Chief”)

who resides at:

(residence street name and number)

(city or town, zip code)

(county)

(mailing address if different from residence address)

hereby nominate myself and accept such nomination for the office of director for a ___ (two/four) year term on the board of
directors of the Conifer Area Park & Recreation District (the “District”) at the May 3, 2011 election and will serve if elected.

I affirm that I am an eligible elector of the District and I am an eligible elector at the date of signing this Self-Nomination and
Acceptance form.

I am an eligible elector because I am registered to vote in Colorado and I am (mark at least one):

_____ A resident of the District, or a resident of an area to be included in the District, and have been in residence for not
less than 30 days; or
_____ The owner (or spouse of the owner) of taxable real or personal property situated within the boundaries of the
District, or of an area to be included in the District, whether said person resides within the District,
Spouse’s Name, if property is owned in spouse’s name: _________________________________
_____ A person who is obligated to pay taxes under a contract to purchase taxable property within the District, or of an
area to be included within the District.

I further affirm that I am familiar with the provisions of the Fair Campaign Practices Act as required in § 1-45-110 of the
Colorado Revised Statutes. I shall not, in my campaign for this office, receive contributions or make expenditures exceeding
twenty dollars ($20) in the aggregate; however, if I do so, I shall thereafter file all disclosure reports required under the Fair
Campaign Practices Act.

(printed name of candidate) (telephone number of candidate)

(signature of candidate) (date)

________________________________________________
(email address, if applicable)

Information provided by the witness who is a registered elector:

(residence street name and number)

(city or town, zip code)

(county)

(mailing address if different from residence address)

(printed name of witness) (telephone number of witness)

(signature of witness) (date)

For Use by the Designated Election Official:

Received on: (Date), at: (Time) Received by: (Name)

Self-Nomination Form Deemed:

Sufficient on: .
Not Sufficient on: Candidate Notified on: (Date)
Received Amended Form on: (Date/Time)
Amended Form Sufficient on: (Date/Time)

________________________________________________________________________________________________

PROCEDURAL INSTRUCTIONS: Form must be filed with the Designated Election Official (DEO) of the
District not less than the close of business 67 days prior to the special district election to be held May 3, 2011,
which date is Friday, February 25, 2011. While the deadline for filing is the close of business 67 days before the
regular election, the deadline by which any insufficiency must be cured is 3:00 P.M. on the deadline date. To
ensure time to amend the form if it is not sufficient, it is strongly recommended that prospective candidates
submit their Self-Nomination and Acceptance form earlier than the deadline. To meet Fair Campaign Practices
Act requirements, this form must be filed with the Secretary of State no less than 60 days prior to the regular
election.

Sue Blair, Designated Election Official

c/o Community Resource Services
3855 Lewiston Street, Suite 140
Aurora, CO 80011
Monday through Friday, 8:00 a.m. to 5:00 p.m.
Telephone: (303) 381-4960
Fax No.: (303) 381-4961
Email: sblair@crsofcolorado.com