HomeMy WebLinkAbout501s CANDIDATE INTENTION STATEMENT
Candidate Intention Statement Type or Print in Ink. Dat '
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Check One: Initial ❑Amendment (Explain)
JUL 1 6 201 For Official Use Only
CITY CLERKS ".
1. Candidate Information:
NAME OF CANDIDATE (Last First, Middle Initial) DAYTIME TELEPHONE NUMBER FAX NUMBER (optional) E -MAIL (optional)
C uOt as h [ 2 Dn ���i> �aa - 176 ( q , 1 ) 6aR-7
STREET ADDRESS CITY STATE ZIP CODE
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OFFICE SOUGHT (POSIITION TITLE) AGENCY NAME DISTRICT NUMBER, if applicable. NON - PARTISAN
U _ Co T
U 1 (c• (-` f PARTY:
OFFICE JURIS ICTION
❑ State (Complete Part 2.) Z
X Ity ❑ County ❑ Multi-County: (Name of Multi- County Jurisdiction) (Year of ( Election)
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)
❑ 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 —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 f (t a 'f6rnia t he f goi q is a nd correct.
Executed on / Signature / l
montV day, year) (Candidate)
FPPC Form 501 (April /2011)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (8661275 -3772)
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