I, _________________, do hereby declare myself as a candidate for election to the office of ___________________. (__ Initial here if the office for which you are running is for the balance of an unexpired term.) I am a registered voter. If elected, I will qualify and accept the office of __________________ and serve to the best of my ability. I request my name be placed on the official ballot of the district for the election to be held on the ___ day of _______, 20__, and that my name appear on the ballot as follows:

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_____ (Print name above) _____

My current residence address is

and my telephone number is .

I desire the following occupational designation to appear on the
ballot under my name:

_____ (Print desired designation, if any, above) _____

This occupational designation is true and in conformance with § 13107 of the Elections Code.

I am aware that any person who files or submits for filing a declaration of candidacy knowing that it or any part of it has been made falsely is punishable by a fine or imprisonment, or both, as set forth in § 18203 of the Elections Code.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Executed on ?, 20__,

at (Place)

_____ (Signature of Candidate) _____