13.06.010 Letter of Intent Form

I, __________________ , being duly sworn, depose and say: That I am a candidate for the office of ___________ ; That I am an enrolled member of the Turtle Mountain Band of Chippewa Indians; That I am at least 25 years of age or over; that I have not been convicted of a felony; have not been convicted of a misdemeanor of fraud, embezzlement, forgery or thefts of monies entrusted to the Tribal Government, and (for the Office of Tribal Chairman, Chief or Associate Judge, Chief Clerk of Courts, Judicial Chairperson, that I reside in Rolette County) or (for the office of Tribal Representative, Judicial Board Representatives, that I reside in District # ).

That I hereby authorize the Tribal Election Board of the Turtle Mountain Band of Chippewa Indians to do a background check on myself to determine whether I am qualified to be a candidate for the office of ; provided, that such information shall not be used for any other purpose than as stated.

I hereby certify that the foregoing statements are true and correct and are made for the purpose of establishing my eligibility for candidacy for Tribal Office. If any material statement made in this Notice is false, such false statement may serve as grounds for my removal from Tribal Office.

Therefore, I hereby request that my name be printed on the election ballot:

_____________________________________________________________________________

(Please print your name EXACTLY as you wish it to appear on the ballot.

_____________________________________ ___________________________________

Print (First, Middle, Last) Social Security Number

______________________________________ ___________________________________

Date of Birth Telephone Number

_____________________________________ ___________________________________

Mailing Address City, State, Zip

______________________ ___________________________________

Date Signature of Candidate

Subscribed and sworn to me before this __________ day of ____________, 20____

______________________________________ ___________________________________

Notary Public My Commission Expires

Received by Election Board: Date: _ Time: _

Initials of Election Board designee:

Initials of Candidate: _