Form 501 - 2012 InitialCandidate Intention Statement
Check One: Wnitial ❑Amendment (Explain)
. Candidate Information:
Type or Print in Ink.
Date Stamp
CANDIDATE INTENTION STATEMENT
For Official
NAME OF CANDIDATE (Last, First, Middle Initial) DAYTIME TELEPHONE NUMBER FAX NUMBER (optional) E -MAIL (option 1) ✓�4� �+ W G GAS
W0CJcxM.d , ��.ry J . (Ifo8 ) 891-`72 -b`r ( > PWC';7WeidQ
STREET ADDRESS CITY STATE ZIP CODE
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OFFICE SOUGHT (POSITION TITLE) AGENCY NAME r / I DISTRICT NUMBER, if applicable. NON- PARTISAN
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PARTY:
OFFICE JURISDICTION /�
El state (Complete Part 2.) J'o ! /
,,If City ❑ County ❑ Multi- County: (Name of Multi- County Jurisdiction) (Year of Election)
2. State Candidate Expenditure Limit Statement:
(CaIPERS and Ca1STRS candidates, judges, judicial candidates, and candidates for local offices do not complete Part 2.)
Primary /general election Special /runoff election
(Year of Election) (Year of Election)
(Check one box)
[:11 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: and I accept the voluntary expenditure ceiling for
the general or special run -off election.
(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 Stat Ca' rnia that the f regoing is tr and correct.
-7 t Z
Executed on S ature
(month, day, year) (Candidate)
FPPC Form 501 (April/2011)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)