HomeMy WebLinkAboutBallot Designation Worksheet - KellyRiverside County, Registrar of Voters
t BALLOT DESIGNATION WORKSHEET
�,,..,. November 5, 2024 Genera! Election (Elections Code §§ 13107,13107.3,13107.5; California Code of Regulations § 20711)
This entire form must be completed, or it will not be accepted and you will not be entitled to a ballot designation. DO NOT LEAVE ANY RESPONSE
SPACES BLANK. If information requested is not applicable, please write "NIA" in the space provided, otherwise the information MUST be provided. UPON
FILING, THIS WORKSHEET WILL BE A PUBLIC DOCUMENT.
Candidate Name. q3lAl `een �e d L ki Gender (optional, for translation use only):
Office: P `0e eJ+ C► Cmmei 1 Email: �
Candidate Home Address: PGULm `De5es�'t CA gaA(00
Information
Mailing Address: _
Business Address: Pcl m `Deg e�f+ I C A 9 �aV)
hiPhone Numbers) ►
�5Fax:
Attorney Name (or other person authorized to act on your behalf): ► o iA
IF—
Attomey
Information 2 Address:
Phone Number(s)
0 Business: Mobile: Fax:
You may select as your ballot designation one of the following designations:
(a) Your current principal profession(s), vocation(s). or occupation(s) [maximum total of three words, separated by a slash
(b) The full title of the public office you currently occupy and to which you were elected.
(c) "Appointed [full title of public office]" if you currently serve by appointment in an elective public office and are seeking election to the same office or
to some other office.
(d) "Incumbent" if you were elected (or, if you are a Superior Court Judge, you are a candidate for the same office that you hold) to your current
public office and seek election to the same office. NOTE: A candidate for the office of Representative in Congress, Member of the State Board
of Equalization, State Senator, or Member of the Assembly shall not choose the word "incumbent" as a designation to appear on the
ballot.
(e) "Appointed Incumbent" if you were appointed to your current elective public office and seek election to the same office.
Proposed Proposed Ballot Designation(s): C O u-n C t, rn erA e r•
Ballot 3 Alternate Ballot Des' nations 1: C 1 T4 C o Nm C l l M e rn be r
Designation(s)
Alternate Ballot Designation(s) 2: i
In the spaces provided on the next aagefs): .�
(a) Describe why you believe you are entitled to use the proposed ballot designation. 2:
(b) If your proposed ballot designation contains one or more slashes ("r) separating words in your ballot designation for separate prid&al pre sgion(s),
vocation(s), or occupation(s) (collectively known as "PVOs"), complete a justification section for each separate PVO.
(c) Attach any documents or exhibits that you believe support your proposed ballot designation. 3
(d) If using the title of an elective office, attach a copy of your certificate of election or appointment. -4 Sa t3�
(e) Any supporting documents will not be returned to you. Do not submit originals. o
sr -
It is your responsibility to justify your proposed ballot designation and to provide all requested details.
If your proposed ballot designation includes the word "volunteer," indicate the title of your volunteer position and the name of the entity for which you volunteer
along with a brief description of the type of volunteer work you do and the approximate amount of time involved. You may only use the ballot designation
"community volunteer" if you volunteer for a 501(c)(3) charitable, educational, or religious organization, a governmental agency or an educational institution.
You may not use "community volunteer" together with another designation.
Rev 0512024
Riverside County, Registrar of Voters
BALLOT DESIGNATION WORKSHEET
+>,- ,.•' November 5, 2024 General Election (Elections Code §§ 13107,13107 3 13107 5, California Code of Regulations § 20711)
Page 2
If your proposed ballot designation contains one or more slashes ("P) separating multiple principal profession(s), vocation(s), or occupation(s) (collectively
known as WiDs'), complete a justification section for each separate PVO.
Justification
for use of
Proposed
Ballot
Designation(s)
If you are
proposing
alternate ballot
designations,
please provide
justification for
use of those on
Page 3.
Justification for use of 1" PVO:
Ci� rec�rrd5 conA"irm m(3
SeTVt'C� .
Current or most recent 'ob title: C tllvii C Ax errn \,je r' Start/End Dates: l a
a o 1
Employer Name or Business: C L T4 � 90Am 5 PN 1
Person who can verify this information:
Name: (\n-T Mj % Q(2 ki%Q, Phone Number(s) � (� 3 Gt.
for use 6f 2nd PVO:
Current or most recent job title: Start/End Dates:
Employer Name or Business:
Person who can verify this information:
Name: Phone Numberi.$): Email:
ti
Justification for use of 3rd PVO:
�—
Current or most recent job title: Start/End Dates.
Employer Name or Business:
Person who can verify this Information:
Name: Phone Number(s): Email:
Before signing below, answer/initial the following questions. Does your proposed ballot designation:
1)
Use only a portion of the title of your current elected office?
1 Dyes Ao
Initial
2)
Non -judicial candidates: Use only the word'Incumberif for an elective office to which you were appointed? Nck U5 ed Dyes Ao
Initia
3)
Use more than three total words fF'r your principal professions, vocations, or occupations? I
Dyes o
Initial
4)
Suggest an evaluation of you, such as outstanding, leading, expert, virtuous, or eminent?
Dyes o
Initia
5)
Refer to a status (Veteran, Activist, Founder, Scholar), rather than a profession, vocation, or occupations?
❑Yes
Initia
6)
Abbreviate the word 'retired?
❑Yes
Fo
Initia
7)
Place the word 'retired' after the words it modifies? Example: Accountant, retired
Dyes
Initla
8)
Use a word or prefix (except "retired') such as 'former or "ex ' to refer to a former profession, vocation, or occupation?
Dyeslo
Initia
9)
Use the word 'retired' along with a current profession, vocation, or occupation? Example: Retired Firefighterrreacher
Dyes
In iti
10)
Use the name of a political party or political body?
Dyest
Initia
11)
Refer to a racial, religious, or ethnic group?
Dyes
Initi
12)
Refer to any activity prohibited by law?
Dyes ta'Flo
Initia
If the answer to any of these questions is "yes," your proposed ballot designation is likely
to be rejected.
X
o 7 ►
3 4 1
C Signed: Month
Day
Year
For your
reference, attached are Elections Code sections 13107-13107.3, and 13107.5, and California Code of Regulations (CCR),
title 2, section 20711.
You also may wish
to consult CCR, title 2, sectons. 20712-20719 (found at www.sos.ca.govl.
Rev 05l2024
r. Riverside County, Registrar of Voters
BALLOT DESIGNATION WORKSHEET
November 5, 2024 General Election (Elections Code §§ 13107, 13107 3, 13107.5; California Code of Regulations § 20711)
Page 3
COMPLETE; THIS PACE ONLY IF one or more Alternate Ballot Designation(s) are Erovided. If this page is not applicable, please initial:
Justification for
Altemate Ballot A
Designation(s)1
Justification for
Alternate Ballot B
Designation(s) 2
Justification for use of 161 PVO.
5 A mT-- Ctrs Q
e aR
Current or mosl rece--t lob title:
Start/End Dates
Employer Name or Business
Person who can verify this information:
Name:
Phone Numben:si:
Email
Justification for use of 2.1 PVO:
Current or most recent job title
StarUEnd Dates
Employer Name or Business
Person who can verify this information:
Name
Phone Numbers):
Email
Justification for use of and PVO:
Current or most recent mob title
Start(End Dates
Employer Name or Business
Person who can verify this information:
Name:
Phone Number(s):
ram,
Email
Justification for use of 1*t PVO:
r�
Current or most recent job title:
StarUEnd Dates art
Employer Name or Business:
Person who can verify this information:
Name:
Phone Number(s):
Email:
Justification for use of 2nd PVO:
Current or most recent'ob title:
Start/End Dates
Employer Name or Business:
Person who can verify this information:
Name:
Phone Number(s):
Email:
Justification for use of 31d PVO:
Current or most recent'ob title:
Start/End Dates:
Em o er Name or Business:
Person who can verify this information:
Name:
Phone Number(#
Email:
Rev 0512024
United,,States of America
li Efeon
Certi Cate oc
- State of California,
County of amide SS.
k
I, C�' cake .C. J�acHa ,City Clerk,
rFy • � S•
# of the City of Yahn JOwed , State of California,
certify, that at a geread Atunicipcd Election,
held in the City on Jw, dag, Nn 3
was elected to the office of
as appears by the official returns of the election and the statement of
votes cast now on fife in my office.
I affix my hand and official seat this
90tP day of Dece d,", 202V
CP46'e-"z- 4,
Cferk,
OAT. R Af IRMAN
O ALL G +NCEFOR
PUBLIC OFFICES' A
EMPLOr
,State of Cafi ornia,
+ f
} Ctountiy of
2 _ �
The Execution of this oath is Requircdby Artick X , ,Section.3, of the
C'onstituIion of the ,State of C'af fornia.
NA&&ert ice
o sofetr n(y affirm that I wiff support and defend the Constitution Of
the United .States and the Constitution of the .State of C6fornaa
against aff eneriaies, fore rx and domestic, that 1 uda bear true faitl
and aAegiance to the Constitution of the United ,States and the =_
Constitution of the .Stare of C'afiforni a, that I ta, tfaas obfi uti.on
freely, ithout any mewaf reservation or purpose o evwion and that I
wiff weff andfai u(fp discfiaQ7e thw Aties upon wh" I am about to
enter,
Subscribed andswom to before me this
day of n9g4.f1 v
R
} 4 w
icy cure of Of icer; m�nrs:eringc7a.€� }t;..� _y _}.
CGdbV Ceti 'L era i
'T#ek of off er i,TuterilgQa# _ <.