HomeMy WebLinkAboutForm 501- Gary Phillips for Mayor 2015Candidate Intention Statement
Check One: [0Initial ❑Amendment (Explain)
Type or Print in Ink.
Date Stamp
JUL - 2 2015
Time:
City Clerk's Office
Citv of San Rafae
CANDIDATE INTENTION STATEMENT
For Official Use Only
1. Candidate Information:
NAME OF CANDIDATE (Last, First Middle Initial) a.� DAgYTIME �-.TELLLEPHONE NUMBER FAX NUMBER (optional) E-MAIL (optional)
I-V
STREET ADDRESS CITY STATE ZIP CODE
OFFICE SOU�GHT (POSITION TITLE) AGENCY NAME` DISTRICT NUMBER, if applicable. [j�ION-PARTISAN
�`.r<"j/� C:_ �s PARTY:
OFFICE JURISDICTION
❑ State (Complete Part 2 )
E3 City ❑ County ❑ Multi -County: (Name of Multi -County Jurisdiction) ear of 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 or Electron)
Primary/general election (Year of 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: I 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:
I certify under penalty of perjury under the laws of the State of Calif is that the r going is true and correct.
�J
Executed on _-_ / 1 �_ I is Signature
(month, day, year) (Ca idate) FPPC Form 501 (April/2011)
ii FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)