HomeMy Public PortalAbout00. Form 501 IntialCandidate Intention Statement
Check One: m Initial []Amendment (Explain)
1. Candidate Information:
RCEIVE
NOV 2 9 2021
CITY CLERK
For Official Use Only
NAME OF CANDIDATE (Last, First Middle Initial) DAYTIME TELEPHONE NUMBER FAX NUMBER (optional) EMAIL (optional)
Medina, Silviano (Sal) ( 626 ) 833-0170 ( Sal@Sa14Claremont.com
STREETADDRESS CITY STATE ZIP CODE
257 E. Green Street Claremont CA 91711
City Council
OFFICE JURISDICTION
❑ State (Complete Part 2.)
❑ City ❑ County
City of Claremont
❑ Multi -County: (Name of Multi -County Jurisdiction)
2. State Candidate Expenditure Limit Statement:
(CalPERS and Ca/STRS candidates, judges, judicial candidates, and candidates for local offices do not complete Part 2.)
(Check one box)
❑ I accept the voluntary expenditure ceiling for the election stated above.
❑ I do not accept the voluntary expenditure ceiling for the election stated above.
NON-PARTISAN OFFICE
(Check one box, if applicat
2024 ® PRIMARY/ GENERAL
(Year of Election) ❑ SPECIAL/ RUNOFF
Amendment:
Q 1 did not exceed the expenditure ceiling in the primary or special election held on / / and I accept the voluntary expenditure
ceiling for the general or special run-off election.
(Mark if applicable)
❑ On, —J� I contributed personal funds in excess of the expenditure ceiling for the election stated above.
3. Verification:
I certify under penalty of perjury under the laws of the State of California th t the foregoing is true and correct.
Executed on 11 29 21 Signature "�
(month, day, year) (Candidate) FPPC Form 501 (August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov