HomeMy WebLinkAbout2012 • - CANDIDATE INTENTION STATEMENT
Candidate Intention Statement Type or Print in Ink Date Stamp '
RECEMD • - •
Check One: For Official Use Only
❑Amendment (Explain) U L l 16 2012
Ci CLERICS DEPT.
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
EJ
OFFICE SOUGHT (POSITION TITLE) AGENCY NAME DISTRICT NUMBER, if applicable. NON - PARTISAN
PARTY:
OFFICE JURISDICTION
r ❑� State (Complete Part 2.) r „
ICJ City ❑ County ❑ Multi- County: (Na of Mu i -C unty Jurisdiction) (Year of EI ction)
2. State Candidate Expenditure Limit Statement:
(CalPERS and CaISTRS 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)
❑ 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:
O 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 per'ury under the laws of the State of Cali ornia t at the foregoing is true and correct.
Executed o Signature
(..nt4, d y, yea (Candidate)
FPPC Form 501 (April/2011)
FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275.3772)