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Reci ient Committee COVER PAGE <br /> P Type or print in ink. Date Stamp <br /> Campaign Statement ' �: � � • 1 <br /> Cover Page <br /> (Govemment Code Sections 84200-84216.5) p�ge of <br /> Statement co ers period Date of election if applicable: <br /> (Month, Day,Year) G i_� -- For Official Use Ony <br /> from <br /> SEE INSTRUCTIONS ON REVERSE through —���/ vl(� <br /> 1. Type of Recipient Committee: All Commfttees-Complete Parts 1,z,s,a�a a. 2. Type of Statement: <br /> ❑ Officeholder,Candidate Controlled Committee ❑ Primarily Formed Ballot Measure ❑ Preelection Statement ❑ Quarterly Statement <br /> Q State Candidate Election Committee Committee [�emi-annual Statement � Special Odd-Year Report � <br /> Q Recall Q Controlled Termination Statement <br /> (AlsroCOmpletePaRS) onsored � ❑ Supplemental Preelection . <br /> � SP (Also file a Form 410 Termination) Statement-Attach Form 495 <br /> (Also Complete Part 6) <br /> General Purpose Committee ❑ Amendment(Explain below) <br /> Q Sponsored � Primarily Formed Candidate/ <br /> Q Small ContributorCommittee Officeholder Committee <br /> Q Political Parly/Central Committee (Also Complefe Part n <br /> 3. Committee Information �•D. NUMBER% j Treasurer(s) <br /> COMMITTEE NAME(OR CANDIDATE'S NAME IF NO COMMITTEE) NAME OF TREASURER <br /> � GrU�CJ� O � ���W�C�"1.J C` ` ��� MAILING A�GI.S� �QI��J�� <br /> �� y � <br /> 7.� � S-&��P� <br /> STREET�RES�O� B����� CITY/�� �l STATE 2IP CODE AREA CODEIPHONE <br /> � �� � - � <br /> CITY STATE ZIP CODE AREA CODE/PHONE NAME OF SSISTANT TREASUR , IF ANY <br /> Q ufc� �'c�i C� ���.3 1v5�-369-�,�($ �co �1 <br /> MAILING DDRESS(I DIFFERENT) .AND STREET OR P.O. BOX MAILING ADDRESS <br /> � � � -� n� �"�� �'�D ,r�l�,�� 5-�-�e� <br /> CITY����a� � t�� STATE ZIP C�DE ���`'CSODE/PHONE CITY l , STATE ZIP CODE AREA CODE/PHONE <br /> C/� �?L' � <br /> OPTIONAL: FAX I E-MAIL ADDR S OPTIONAI: FAX/E-MAIL ADDR S <br /> 4. Verification <br /> I have used all reasonable diligence in preparing and reviewing this statement and to the besl of my knowledge t ' formation contained herein and in the attached schedules is true and complete. I certify <br /> under penalty of pery'ury under the laws of the State of Califomia that the foregoing is true and correct. <br /> Executed on �� �� �Q L gy ^ " <br /> Date Signeture ot Treasurer or Assistant Treasurer <br /> EXecuted on �� By SlgnaNre of Controllirg Officeholder,Candidate,State Measure Proponent or ResponsiMe Officer W Sponsor <br /> Executed on By <br /> Date SignaNre of ContrdNng Officeholder,Carxf�date,State Measure Proponent <br /> Executed on By <br /> Date SignatureoiContrWlingOfficeholder.Candidate,StateMeasureProponent FPPC Form 460(January/05) <br /> FPPC Toll-Free Helpline:8661ASK-FPPC(866/2T5-3772) <br /> SWte of California <br />