HomeMy WebLinkAbout2011 - Form 501 Initial
Candidate Intention Statement Type or Print in Ink. DaiU{t~l1
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Check One: o Amendment (Explain)
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1. Candidate Information:
NAME OF CANDIDATE (Lasf, Firsf, 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. RNON-PARTISAN
C. \. 't'; (C!C)\.')t-J c. \L C\ 'r1 O~ G-, ~(to'1 PARTY:
OFFICE JURISDICTION
o State (Complete Part 2.)
.City o County o Multi-County: -
(Name of Muffi-County Jurisdiction)
2. State Candidate Expenditure Limit Statement:
(CaIPERS candidates, judges, judicial candidates, and candidates for /ocal offices are not required to complete Part 2)
Primary/general election Special/runoff election
(Year of Election) (Year of Election)
(Check one box)
o I accept the voluntary expenditure ceiling for the election stated above.
o I do not accept the voluntary expenditure ceiling for the election stated above.
Amendment:
o I 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)
o 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
Executed on "'2..~ ~UC:tt)<:.. r "'UD \ Signature -
(month, day, yelr)
FPPC Form 501 (January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)