1. Neighborhood Council Elections
2012 Candidate Filing Form
ATTENTION: All candidates whose names will appear on the ballot must complete and submit this form with the
Department of Neighborhood Empowerment by the close of business day on July 5, 2012. Any forms received after this
day will not be processed. There are no write-in candidates. Candidates must provide documentation and any other
applicable identification to establish their stakeholder status for the position for which they are applying by this
deadline, otherwise their filing will not be complete. For more information regarding this form and acceptable forms of
documentation, please go to www.empowerla.org or call (818) 293-VOTE (8683).
Region 1 Neighborhood Council Elections
CANDIDATE INFORMATION (PLEASE PRINT CLEARLY)
First Name: _______________________ M.I.: _______ Last Name: ___________________________
Street Address: ____________________________________________________ Zip Code: ________
Phone Number: _______________________________ Email: _______________________________
STAKEHOLDER CATEGORY (PLEASE PRINT CLEARLY)
I AM A NEIGHBORHOOD COUNCIL
STAKEHOLDER BECAUSE: (Stakeholder status is based on the stakeholder status you select in this section.)
I AM A RESIDENT OF THE NEIGHBORHOOD COUNC I L (NC) AND LIVE AT :
__ See address above
__ Street Address:_________________________________________________________________Zip:________
I OWN A B U SINE SS I N THE NC AT: OR I WORK IN THE N C AT:
Name of Business or Place of Work:_____________________________________________________________
Business Address:_________________________________________________________________Zip:________
I OWN PROPERTY IN THE NC AT:
Property Address:__________________________________________________________________Zip: _______
I HAVE A VESTED INTEREST IN THE NC BASED ON THE FOLLOWING FACTUAL BASIS:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
OTHER: ___________________________________________________________________________________
Address: ___________________________________________________________________________________
I QUALIFY AND AM APPLYING FOR THE FOLLOWING NC BOARD SEAT:
____________________________________________________________________________________________
(WRITE BOARD POSITION NAME HERE)
I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT:
Signature:____________________________________________________________________ Date:_________________
Mail Completed forms can be returned in 3 ways:
to: Department of Neighborhood Empowerment – E
11410 Sylvan Street, 4th FL, Van Nuys, CA 91331
Mail to: Department of Neighborhood Empowerment – Elections Division
14410 Sylvan Street, 4th FL, Van Nuys, CA 91401 (818) 582-2849
Email to: elections@empowerla.org or Fax to:
Email to: elections@empowerla.org OR Fax to: (818) 582‐2849
TO BE FILLED OUT BY ELECTION DIVISION STAFF
Complete Incomplete
Documentation: (ID) ______________________________ (STATUS) ________________________________________
Verified by (print): ___________________________________________________________________________________
Signature of Verifier:____________________________________________________ Date: ______________________

2. Neighborhood Council Elections
Candidate Statement
First Name:_______________________________________ Last Name:______________________________________
All candidates have the option of submitting a Candidate Statement and picture as part of their Candidate Filing
application. Every candidate must adhere to the following guidelines when submitting a Candidate Statement:
• Must fit in the designated area below;
Region 1 Neighborhood Council Elections
• Must not exceed 150 word count limit;
• Must be at least 12-point font (if typed);
• Must be submitted no later than July 5, 2012; and,
• May not include any pictures, profanity or comments about any other candidate.
Additionally, a candidate may submit translated version(s) of the original statement, which must comply with all
aforementioned criteria. Candidate Statements will be available on www.empowerla.org and at the polling place on
Election Day. Please print clearly as the statement will scanned as is and not retyped. Thank you!
I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT:
Signature:____________________________________________________________________ Date:_________________