Candidate Statement Form 2019 Consolidated Election Name of Candidate as it will appear on ballot Office sought Mailing Address City State Zip CA Residence Phone Business Phone Cell Phone Email Address I ELECT TO FILE A CANDIDATE STATEMENT I have read the Candidate Statement section(s) of the Registrar of Voters Candidate Filing Guide for this election, and affirm that my candidate statement as submitted on this form complies with California Elections Code and Registrar of Voters policy. 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. I understand that my candidate statement will be translated and printed in Spanish. When translating my candidate statement in Spanish, I request that the Registrar of Voters (check only one option below):  ☐ Translate my statement using female nouns and pronouns, or  ☐ Translate my statement using male nouns and pronouns. Signature of Candidate Date Return signed Candidate Statement Forms along with your candidate statement deposit: By Mail or In Person: San Bernardino County Registrar of Voters, 777 E. Rialto Ave, San Bernardino, CA 92415 By Email & Phone: Scan your signed Candidate Statement Form and email to communications@sbcountyelections.com, and Call the Registrar of Voters at 909-387-8300 to pay your candidate statement deposit by credit card. To receive assistance with completing and returning this form, please email us at communications@sbcountyelections.com and attach the electronic copy (.docx or .doc) of your candidate statement. Registrar of Voters staff will contact you to schedule an appointment with a Candidate Filing Clerk. CANDIDATE NAME: Age: Occupation: FILED Word Count: I affirm that I want my candidate statement printed in theVoter Information Guide. Signature of Candidate