SELF- NOMINATION AND ACCEPTANCE
C.R.S 1-13.5-303; 1-45-109(1); 1-45-110; SOS CPF Rule 16; 1-4-908(1); 1-4-912

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

who reside at:	______________________________________
		(Residence Street Name and Number)

		______________________________________
		(City or Town, Zip Code)

		______________________________________
		(County, State)

		______________________________________
		(Mailing Address, if different from residence address)

whose email address is: ______________________________________		
				(Email Address)
hereby nominate myself and accept such nomination for the office of Director for a  three-year term on the Board of Directors of  the Salida Hospital District at the regular election on May 5, 2020, and will serve if elected.			
I affirm that I am an eligible elector of the Salida Hospital District and am an eligible elector at the date of signing this Self-Nomination and Acceptance Form (or letter).

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

	A resident of the District, or area to be included in the district; or

	The owner (or spouse/civil union partner of owner) of taxable real or personal property situated 
within the boundaries of the District, Spouse’s Name, if property is in spouse’s name:  

	A person who is obligated to pay taxes under a contract to purchase taxable property within the 
District.

Mark here _____ if you are a member of an executive board of a unit owner’s association, as defined in § 38-33.3-103 of the Colorado Revised Statutes, located within the boundaries of the district for which you are running for office. 

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, and I will not, in my campaign for this office, receive contributions or make expenditures exceeding $200 in the aggregate during the election cycle, however, if I do so, I will thereafter file all disclosure reports required under the Fair Campaign Practices Act.

DATED   this            day of                           , 2020.		WITNESSED by the following registered elector:

_______________________________________		______________________________________
(Signature of Candidate)						(Signature of Witness)

_______________________________________		______________________________________
(Printed Full Name of Candidate)					(Printed Full Name of Witness)

_______________________________________		______________________________________
(Email Address)							(Residence Address)

_______________________________________		______________________________________
(Telephone Number)						(City or Town, Zip Code)

For Use by the Designated Election Official:

Received on: _______________________, at:_________ Received by: _________________________________                               
			(Date)			(Time)					(Name)

Self-Nomination Form Deemed: 

Sufficient on: ________________________ (Date/Time)
Not Sufficient on: _____________________ Candidate Notified on: ___________________ (Date)              
Received Amended Form on: __________________________ (Date/Time)
Amended Form Sufficient on: __________________________ (Date/Time)	

County in which the district court that authorized the creation of the special district is located: _______________ County.

Copy sent to Secretary of State on:                           (Date) [If the election is not cancelled, the self-nomination and acceptance form must be filed with the Secretary of State no later than the 60th day prior to the election, March 6, 2020.].                                    										

***ATTENTION: DO NOT FILE WITH THE SECRETARY OF STATE IF YOUR ELECTION IS CANCELLED!