16 - OC LAFCO ElectionsDECLARATION OF QUALIFICATION TO VOTE James Ferryman Costa Mesa Sanitary District 628 W. 19th Street Costa Mesa, CA 92677-2716 jferryman@cmsdca.gov I, ___________________________________,* hereby attest that _____________________________**has been authorized by the Board of _____________________________________to vote in the Orange County Special District Selection Committee election. The Board also designated _________________________ ***as the alternate voting member. Name and Title*:_____________________________________ Signature*:________________________________ Date : __________________________ *Must be signed by either Board President or Board Secretary ** Must be a member of the Board ***Must be a member of the Board Completed forms must be received by LAFCO prior to 3 PM, Tuesday, June 13 , 201 4. Forms must be delivered to Orange County LAFCO by: (1) Email at: cemery@oclafco.org , or (2) Mail at: Orange County LAFCO 12 Civic Center Plaza, Room 235 Santa Ana, CA 92701 Attn: Carolyn Emery, or (3) FAX at: (714) 834-2643, Attn: Carolyn Emery ITEM NO. 16
BALLOT ALTERNATE SPECIAL DISTRICT MEMBER Local Agency Formation Commission Term of Office Expires 06/30/20 1 4 ____________________________________________________ Print Name of District Certification of Voting Member I, , hereby certify that I am: Print Name Here the presiding officer of the above named district. a member of the Board of the above -named district designated to vote in the absence of the presiding officer pursuant to G.C. §56332(a). I have submitted proof of this designation to the Executive Officer of LAFCO. Signature Date CANDIDATES FOR ALTERNATE SPECIAL DISTRICT MEMBER OF LAFCO: (Check one ONLY.) _______ James Fisler, Mesa Water District _______ Rich Freschi, Serrano Water District _______ Abstain