HomeMy WebLinkAboutForm 501 - InitialCANDIDATE I
Candidate Intention Statement Type or Print in Ink.
cy Date Stamp
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FORM •
For Official Use Only
Check One: Initial ❑ Amendment (Explain)
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.
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PARTY:
OF ICE JURL81DICTION
❑ State (Complete Part 2.)
City ❑ County ❑ Multi- County:
(Name ofMUlti- 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)
❑ 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:
Q 1 did not exceed the expenditure ceiling in the primary or special election held on: -i and I accept the voluntary expenditure ceiling for the
general or special run -off election.
(Mark if applicable) -
❑ On I , 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 for and correct.
Executed on -� Signature
(month, day, yeat) _.__,.___._- andi te)
FPPC Form 501 (January/05)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)