501 Candidate Intention „~ ~i iuivrai,
Candidate Intention Statement Type or Prlnt In Ink. ~ c~ ,~ a am ~ ~
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~~~~~ I t w~~J ` For
Check One: Initial ^ Amendment (Explain) ~~~
~TINO CITY CLERK
1. Candidate Information:
NAME OF CANDIDATE (Last, First, Middle Initial) DAYTIME TELEPHONE NUMBER FAX NUMBER (optlonal) 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, iIa
pdiceWa• ON-PARTISAN
OFFICE JURISDICTION
^ State (Complete pad 2.)
^ County ^Mtilti-County:
(Name d Muni-CountyJurisdic0on) (Year o/ E/action)
2. State Candidate Expenditure Limit Statement:
(CaIPERS candidates, judges, Judicial candidates, and candidates for local offices are not required to complete Part 2.)
i-iil~taryigenerai eieciion ~peciaiirunorr election
(Yearo(Elec~ion) (Yearo/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 I 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 1! appNcable)
^ 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 fore a and correct.
Executed on ~ ~ ~ 3 ~ ~ ~ ' Signature ~ I
month, d y, year) an Mate)
FPPC Form 501 (January/05)
FPPC Toll-Free Helpline: 8661ASK-FPPC (866/275-3772)