501 Candidate Intention Statement
Type or Print in Ink.
ANDIDATE INTENTION STATEMENT
Candidate Intention Statement
CALIFORNIA 501
FORM
For Official Use Only
Check One: ~ Initial
D Amendment (Explain)
1. Candidate Information:
NAME OF CANDIDATE (Last. First, Middle Initial)
DAYTIME TELEPHONE NUMBER
FAX NUMBER (optional)
E-MAIL (optional)
C 11 AJJGf
STREET ADDRESS '
~~a )6J>R "'6~9lf
CITY
(9<1") 9 ?6... ?/OO
STATE ZIP CODE
C 9 ro /i
DISTRICT NUMBER, if appliceble. 0 NON-PARTISAN
c-zL.
PARTY:
p( City
o County 0 Multi-County:
(Name of Multi-County JurisdicUon)
(Year of E/ecUon)
2. State Candidate Expenditure Limit Statement:
(CalPERS candidafes, judges, judicial candidafes, and candidates for local offices are not required to complete Part 2.)
(Year of Election)
Primary/general election
(Year of Election)
Special/runoff 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.
Arnendment:
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 foregoing is true
Executed on t!',. <1' - ~ o? Signature e
(month, day, year)
F.PPC Form 501 (January/OS)
FPPC Toll-Free Helpline: 866IASK-FPPC (866/275-3772)