HomeMy WebLinkAboutDeclaration of Candidacy - PerryRiverside County, Registrar of Voters
*_ DECLARATION OF CANDIDACY `: -
Nonpartisan Office — For Use in Local Elections
November 3, 2026, General Municipal Election (Elections Code §§ 20, 200, 8002.5, 8020, 8020.5, 8040,8121, 13105)
For Elections
Officials USE
ONLY
By: tivt4t
Date Issued:
Official Filing Form
Elections
Filed in:
Elections
By Siv'vft,
Date Received
Elections Official
I hereby declare myself a cand;date for the nom;nation/election to the office of L .e e r 4' L T% Jn Cl L D�
to be voted for at the General Municipal Election to be held on November 3, 2026, and declare the following to be true.
Candidate Name 1
and Office My name is ___
First Middlelinitial (optional) Las
IMPORTANT NOTE: A ballot designation is optional. If one is requested, a completed BALLOT DESIGNATION WORKSHEET must be submitted. If
no ballot designation is requested, write "NONE" and initial in the box. (Elections Code §§ 13107, 13107.3)
I request my name and ballot designation to appear on the ballot as follows:
Ballot 4
fl
1 , Candidate
Information F
Name and ballot 2 Prin Your Name for Use on the/Ballot NOinitlals bal of box if
designationron o v / ❑ designation
appear on the t'
ballot Print Ballot De 'nation Requested is preferred.
[If applicable in your City;County] I have a character based name I would like to use instead of a phonetic transliteration (You must complete Character -
Based Name Form )
IMPORTANT NOTE: The Registrar of Voters will publish your name and proposed ballot designation. You may also have a mailing address, residential
address, email and/or phone number published on the election official's website.
ONLY CHECK ONE BOX. Please check the appropriate box to indicate which address you wish to be used for publishing purposes.
Publish ❑ --y Mailing Address:
( ' Apt or Unit #
CltylStatelZlp Code: ��, LAr
.
''--1--t O
4 l�
• Publish❑ Residence Address Re uired :
6Apt, or Unit #
CitylState/Zip Code. L
e (?
r 4
Addresses,
Telephone,
_
❑
Publish — Business Address:
Apt. or Unit #
Internet
Website and
3 City/State/Zip Code:
Email
Publish ❑ —+Telephone (Business):
+
•—
Publish ❑ — Telephone (Evening):
` •
Publish —)' Internet Website:
Publish —> Email:
IMPORTANT: Reverse Side of Page Must Be Completed
Rev: 112025
I meet the statutory and constitutional qualifications for this office (including, but not limited to, citizenship and residency). I am at present an
incumbent of the following public office (if any):
I have not been convicted of a felony involving accepting or giving, or offering to give, any bribe, the embezzlement of public money, extortion
Qualifications 4 or theft of public money, perjury, or conspiracy to commit any of those crimes.
If nominated/elected, I will accept the nomination/election and not withdraw, except as permitted by state law.
x
ature of Candidate
I, 2 -'IA L1 ee rc y , do solemnly swear (or affirm) that I will support and defend the Constitution of the
United States and the Constitution of the State of California against all enemies, foreign and domestic; that I will bear true faith and allegiance
to the Constitution of the United States and the Constitution of the State of California; that I take this obligation freely, without any mental
Oath of Office 5 reservation or purpose of evasion; and that I will well and faithfully discharge the duties upon which I am about to enter.
x
ignature of Candidate
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which
this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of Q \\Ie r e -
Subscribed and sworn to (or affirmed) before me on this 2 ` A day of .)1 , 20 Z.(o , by
1Z?�v, ee r f y _, proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.
Notary Public
or
Other Officer
(Notary Public Seal)
Signature of Notary Public
(or other officer)
Examined and certified by me this '-t'' da 31 , 20 ZIc.
Elections Official
WARNING: Every person acting on behalf of a candidate is guilty of a misdemeanor who deliberately fails to file at t and in a proper place any declaration
of candidacy in the persons possession that is entitled to be filed under the provisions of the Elections Code. (Electio s Code § 18202.)
Rev: 112025