Form 501 - 2012 InitialCandidate Intention Statement
Check One: 2(nitial ❑ Amendment (Explain)
Type or Print in Ink.
Stamp
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INTENTION
For Official Use Only
1. Candidate Information:
NAME OF CANDIDATE (Last, First, Middle Initial) DAYTIME TELEPHONE NUMBER FAX NUMBER (optional) E -MAIL (optional)
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STREET ADDRESS CITY STATE ZIP CODE
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OFFICE SOUGHT (POSITION TITLE) AGENCY NAME DISTRICT NUMBER, if applicable. ON- PARTISAN
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OFFICE JURISDICTION
❑ State (Complete Part 2.)
pI /City ❑ y ❑ Count Multi-County:
u (Name olMu/ti- 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)
(Check one box)
❑ 1 accept 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:
general or special run -off election.
and I accept the voluntary expenditure ceiling for the
(Mark if applicable)
❑ On _J_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 that the foregoing is true and correct.
Executed on -2 C Z Signature :1-«� r�
(month, day, year] (Candidate)
FPPC Form 501 (January/05)
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