HomeMy Public PortalAboutForm 501Candidate Intention Statement
Check One: Initial ❑ Amendment (Explain)
1. Candidate Information:
NA E OF CANDIDATE (Last, First, Middle Initial)
STREET ADDRESS
43Ct W
OFFICE SOUGHT (POSITION TITL }
OFFICE JURISDICTION
❑ State (Complete Part 2.)
Ity ❑ County ❑ Multi -County:
Type or Print In Ink.
For Official Use Only
DAYTIME TELEPHONE NUMBER FAX NUMBER (optional) E-MAIL (optional)
(`(C'i ) 3,5`c.5v l ( tai 9>-7 0 ( &S Su jos("wi--.>; � &
CITY
4 �f -41EZ U-.
AGENCY NAME
STATE ZIP CODE
cA_ <i(-2((
DISTRICT NUMBER, if applicable. OI
7 c3l l
(Name of Multi -County Jurisdiction) (Year of Election)
2. State Candidate Expenditure Limit Statement:
(CalPERS candidates, judges, judicial candidates, and candidates for local offices are not required to complete Part 2_)
Primary/general election Special/runoff election
(Year of Election) (Year of Election)
PARTY:
(Check one box)
g-1-Mccept the voluntary expenditure ceiling for the election stated above.
❑ I do not accept the voluntary expenditure ceiling for the election stated above.
Amendment:
Q 1 did not exceed the expenditure ceiling in the primary or special election held on: _�_J and I accept the voluntary expenditure ceiling for the
general or special run-off election.
(Mark if applicable)
❑ On I contributed personal funds in excess of the expenditure ceiling for the election stated above.
3. Verification:
I certify under penaltyof perjury under the laws of the State of California that th
16L
Executed on 2_ 010 Signature
(month, day, year)
(candidate)
correct.
FPPC Form 501 (January/05)
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)