HomeMy WebLinkAboutForm 501 - HMillerCandidate Intention Statement
Check One: [Initial ❑Amendment (Explain)
Type or Print in Ink.
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JIIUJJwwL 19 2012
CANDIDATE INTENTION STATEMENT
1. Candidate Information:
NAME OF CANDIDATE (Last, First, Middle Initial) DAYTIME TELEPHONE NUMBER FAX NUMBER (optional) E -MAIL (optional)
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PARTY-
OFFICE SOUGHT (POASI�TION[ TITLE) AGENCY[ NAME DISTRICT NUMBER, if applicable. ®NoN- PARTISAN
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OFFICE JURISDICTION
❑ State (Complete Part 2.) q
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[4 City ❑ County ❑ Multi-County: (Name of Multi- County Jurisdiction) (Year of Election)
2. State Candidate Expenditure Limit Statement:
(Ca /PERS and CaISTRS candidates, judges, judicial candidates, and candidates for local offices do not complete Part 2.)
(Year of Election)
Primary (Year of Election)
/general election Special /runoff 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: and I accept the voluntary expenditure ceiling for
the general or special run -off election.
(Mark if applicable)
❑ On —J_J 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 o California that the f r of is true and correct.
Executed on 7 -,>_ Signature A — L/ ---
(month, da , year) (Candidate) FPPC Form 501 (April /2011)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)