HomeMy WebLinkAboutForm 501- Esther Beirne for City Clerk 2015 InitialCANDIDATE INTENTION STATEMENT
Candidate Intention Statement Type or Print in Ink. oats stamp I CALIFORNIA
Check One: ®Initial ❑Amendment (Explain)
JUL 15 2015
ime:
:ity Clerk's Office
`itv of San Rafael
NAME OF CANDIDATE (Last, First. Middle Initial) DAYTIME TELEPHONE NUMBER FAX NUMBER (optional) E-MAIL (optional)
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STREET ADDRESS CITY STATE ZIP CODE
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OFFICE SOUGHT (POSITION TITLE) AGENCY NAME �I [� %� DISTRICT NUMBER, it applicable 154 W NON-PARTISAN
Cr't,) 6i -el P Va pa�E�OF l�%Y Ot= J,41V f�jdr-AGL PARTY.
OFFICE JURISDICTION
❑ State (Complete Part 2 )
❑ City ❑ County ❑ Multi -County: (Name of Multi -County Jurisdiction) (Year of Election)
2. State Candidate Expenditure Limit Statement:
(CaIPERS and CaISTRS candidates, judges, judicial candidates, and candidates for local offices do not complete Part 2)
14f5 Primary/general election Special/runoff election
(Year of Election) (Year of 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 J applicable)
❑ On I 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 0 1�11_I ! S/ 101 6 Signature
(month, day, year)
(candidate) FPPC Form 501 (Apri1/2011)
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)