Form 501 Initial Statement Candidate Intention Statement Dale Stamp
For o dal Use O
Check One: (Initial ❑Amendment (Explain) ny
1. Candidate Information:
E OF CANDIDATE (Last,First,Middle Initial) DAYTIME TELEPHONE NUMBER FAX NUMBER(optional) E-MAIL(optional)
oEN a� A� ioN,1 7 c �GG) �5f3-G�3o c I-Z� jbesbcn)obia(.r�T
DISTRICT NUMBER, it applicable NON-PARTISAN
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PARTY:
OFFICE JURISDICTION
❑ State (Complete Part 2.)
City ❑ County ❑ Multi-County: (Name of Male-Count,Judsdiceon) Haar elation)
2. State Candidate Expenditure Limit Statement:
(Ca= CaISTRS canddates,Judges,ludicral candidates, and candidates for local offices do not complete Part 2)
IN
ll\fir on) Primary/general election (year of electron) 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: —J_ and I accept the voluntary expenditure ceiling for
the general or special run-off election.
(Mark d 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 Stat f 11 oMahe foregoing is true and correct.
Executed on Signature FPPC Form 501 (Jan/2016)
onfh,tlay,year) (Cantlitlate)
FPPC Advice:advice@fppc.ca.gov(6661275-3772)
www.fppc.ca.gov