Form 501 - 2012 InitialCandidate Intention Statement
Check One: '� Initial
❑ Amendment (Explain)
Type or Print in Ink.
1. Candidate Information:
NAME OF CANDIDATE (Last, First, Middle Initial) DAYTIME TELEPHONE NUMBER
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CANDIDATE INTENTION STATEMENT
FAX NUMBER (optional) E -MAIL (optional)
STREET ADDRESS !
CITY -
STATE ZIP CODE
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OFFICE SOUGHT (POSITION-TITLE)
ITLE)
AGEENNC NAME
DISTRICT NUMBER, if applicable.
ON- PARTISAN
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PARTY
OFFICE JURISDICTION
❑ State (Complete Part 2.)
--5(-City ❑ County
❑ Multi-County:
(Year of Election)
(Name of Multi- County Jurisdiction)
2. State Candidate Expenditure Limit Statement:
(CalPERS and CaISTRS candidates, judges, judicial candidates, and candidates for local offices do not complete Part 2.)
(Year of Election)
Primary/general election (Near of Election) Special /runoff election
(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.
Amendment:
0 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 penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Executed on -J`9 J �l t`� I Signature
month, d4, yeas) (Candidate)
FPPC Form 501 (April /2011)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)