Request for Candidate Affidavit
Instructions: To immediately receive a personalized affidavit in PDF format suitable for printing, complete and submit this form (by clicking the Submit button at the bottom of the page). Print the personalized PDF affidavit, have it notarized and deliver it to:

Erin Harper
GreyStone Power
P. O. Box 897
Douglasville, GA 30133

For information call Steve Minor, 770-214-5108.

*Full Legal Name:
*Email Address:
*Residential Address:
*City:
*State:
*Zip Code:
*GreyStone Power District:
*
Please provide a legal description of your primary place of residence:

If you are in any way employed by or financially interested in an enterprise or organization that competes with the Cooperative or a business selling electric energy or supplies to the Cooperative, explain below any facts which make this interest so inconsiderable or incidental so as not to pose a reasonable prospect of a conflict of interest if you were to become a director of the Cooperative:



Sample Affadavit:
STATE OF GEORGIA
COUNTY OF DOUGLAS


This Affidavit is given to ensure that the undersigned, ___________________________ , is aware of, and meets, all of the qualifications for directors of GreyStone Power Corporation ("the Cooperative"), as set forth in Section 4.02 of the Cooperative's Bylaws. The undersigned understands that the Cooperative's Members, its Board of Directors, Nominating Committee and its Credentials and Elections Committee will, in part, rely upon the accuracy of the statements made herein in determining whether the undersigned is qualified to be a candidate for, or serve on the Cooperative's Board of Directors. The undersigned, being duly sworn, hereby deposes, states and agrees as follows:

(a) The undersigned is eighteen (18) years of age or older.

(b) The undersigned is a Member of the Cooperative (the Member of record on the account).

(c) The undersigned's primary place of residence is located within Cooperative District No. ____,
which is described as follows:

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

(d) The undersigned is the Member of record receiving electric service from the Cooperative
and his/her bona fide primary residential abode.

(e) The undersigned is not in any way employed by or financially interested in an enterprise or organization that competes with the Cooperative or a business selling electric energy or supplies to the Cooperative.

If the undersigned IS employed by or financially interested in such a business, the following explains any facts which make this interest so inconsiderable or incidental so as not to pose a reasonable prospect of a conflict of interest if the undersigned were to become a director of the Cooperative:

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

(f) The undersigned is not now, and has not been within the previous twelve (12) months, an employee of the Cooperative.

(g) The undersigned is not now, and has not been within the previous twelve (12) months, an employee or a director of a competing utility.

(h) The undersigned is not now, and has not been within the previous twelve (12) months, a Close Relative of:


a. An employee of the Cooperative, or

b. An employee or director of a competing utility.

"Close relative" is any person who, by blood or in law, including half, foster, step and adoptive kin, is either a spouse, child, grandchild, parent, grandparent, brother, sister, uncle, nephew, aunt, or niece.

(i) The undersigned is not currently a Close Relative of an incumbent director of the Cooperative.

(j) The undersigned has not been convicted of a felony.

(k) The Cooperative's Credentials and Election Committee has never determined that the undersigned has an irreconcilable conflict of interest with respect to the fiduciary duty a director owes the Cooperative.

(l) The undersigned has not been, during the five (5) years immediately preceding the date of this Affidavit, suspended from membership in the Cooperative pursuant to Section 2.01 of the Cooperative's Bylaws.

(m) The undersigned has not been, during the twenty-four (24) months immediately preceding the date of this Affidavit, late in the payment of amounts due the Cooperative for electric service on more than three (3) occasions.

(n) The undersigned has, as of the date of this Affidavit, a credit score of "average" or better, or which is in the top one-half of consumer scores, as determined by a national consumer credit reporting agency.

IN WITNESS WHEREOF, the undersigned has duly executed this Affidavit this _____ day of
____________________, 20______.




Applicant's Signature:_______________________________________


Applicant's Residential Address:
_________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Sworn to and subscribed before me this ______ day of ______________, _________.



__________________________
Notary Public
Authorization for Verification of Affidavit and Other Information, Obtaining
A Credit Report, and Obtaining a Criminal Background Check



I authorize GreyStone Power Corporation, its employees and agents, to do any and all of the following:

• Investigate the accuracy and completeness of this Affidavit and any other information I may provide to GreyStone or any member of GreyStone.

• Investigate any aspect of my background which may be relevant to my qualifications for serving as a director of GreyStone and to my suitability to serve as a director of GreyStone.

• Obtain a credit report or history from any credit reporting service.

• Obtain a copy of my criminal record from any state or local criminal justice agency.






Signature: _______________________________


SSN: ________-_______-___________


Printed Name: ____________________________________



Sworn to and subscribed before me this _____ day of ____________, 20___.





______________________________
Notary Public
Affidavit PDF:



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