Form 501
Candidate Intention Statement
Type or Print in Ink.
Check One: ~nitial
o Amendment (Explain)
1. Candidate Information:
NAME OF CANDIDATE (Last, First, Middle Initial)
DAYTIME TELEPHONE NUMBER
FAX NUMBER (optionaQ
E-MAIL (optional)
pti
~rol
iI NON-PARTISAN
PARTY:
(~~
CITY
CGL
STATE
l....h~
Cc....
AGENCY NAME
~City
o County 0 Multi-County:
(Name of Multi-County Jurisdiction)
ZOOy
(Year of Election)
2. State Candidate Expenditure Limit Statement:
(CaIPERS candidates, judges, judicial candidates, and candidates for local offices are not required to complete Part 2.)
Primary/general election
(Year of Election)
Special/runoff 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: ---1---1_ and I accept the voluntary expenditure ceiling for the
general or special run-off election.
(Mark if appliceble)
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 and correct.
Executed on /1- q-o '1
(month, day, year)
Signature
~.o;/ ~
(Candidate)
EPPC Form 501 (January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)