Form 501 - Intention StatementCandidate Intention Statement
Check One. YN-Initial ❑Amendment (Explain)
NAME OF CANDIDATE (Last First, Middle Initial)
Type or Print in Ink.
DAYTIME TELEPHONE NUMBER
( Ti c)) 519 - 9qV;
CANDIDATE INTENTION STATEMENT
Date Stamp
CITY OF ENCINITAt`,
iTY t''I Foss
-012 A JG 15 PH 5: 34
FAX NUMBER (optional) E -MAIL (optional)
c _415- Te-p-
Use Only
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STREET ADDRESS CITY STATE ZIP CODE
L-L T cc, z�- c Nl�.�S C A 2
OFFICE SOUGHT (POSITION TITLE) AGENCY NAME DISTRICT NUMBER, d applicable
C kT� C J0U" t� f� 6 E�Y1�V NON- PARTISAN
PART
OFFICE JURISDICTION
❑ State (Complete Part 2) 2
%City ❑ County ❑ Multi-County tName of Multi- County Jurisdiction) (Year Election)
2. State Candidate Expenditure Limit Statement:
(CalPERS and CaISTRS candidates judges, judicial candidates, and candidates for local offices do not complete Part 2 )
(Year of Election) (Year of Election) Primary /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:
O 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 I contributed personal funds in excess of the expenditure ceiling for the election stated above
3. Verification:
-!
1 certify under penalty of perjury under the laws of the State of C lif rnia t fs e is true and correct.
Executed on ' /5 � w 4 —2— Signature
nth, day, year) (Candidate) FPPC Form 501 (April /2011)
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