Candidate Statement Form printable pdf download

CANDIDATE STATEMENT FORM

Print / Type name of candidate as it will appear on the ballot

Office sought

Mailing Address:

Street

City

Zip

Contact Information:

Day phone

Evening phone

I ELECT TO FILE A CANDIDATE STATEMENT

 I have been informed that the estimated cost and deposit for my candidate statement is $_________________.

 I agree that if the actual cost of the candidate statement exceeds the amount paid in advance, I will pay the additional sum to the

County of San Bernardino within 30 days of the billing notification for such amount.

 I agree that if the amount billed is not paid within 30 days following such notification, and the Elections Official thereafter

commences legal action against me for the recovery of said amount, I will pay all costs of such action, including costs and

reasonable attorney's fees in an amount to be fixed by the court.

 I have been informed that if the amount paid in advance is more than the actual cost of the candidate statement, the Elections

Official will refund the excess amount within 30 days of the election.

 I agree that any notice, refund or billing pertaining to my candidate statement shall be mailed to me at the address set forth above

and shall be deemed completed upon deposit in the United States mail.

 I have been informed that State Senate and State Assembly candidates are required to accept the voluntary campaign expenditure

limits on FPPC form 501 in order to have a candidate statement printed in the San Bernardino County Voter Information Guide.

 I have been informed that I may withdraw my candidate statement no later than 5:00 p.m. of the next working day after the close of

the candidate filing (nomination) period.

Signature of Candidate

Date

I DO NOT ELECT TO FILE A CANDIDATE STATEMENT

Signature of Candidate

Date

I HEREBY WITHDRAW MY CANDIDATE STATEMENT

 I request the County of San Bernardino to refund the deposit amount paid in advance, within 30 days of the election.

Signature of Candidate

Date

Candidate Statement Form