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Recipient Committee <br /> Campaign Statement <br /> Cover Page <br /> (Govemment Code Sections 84200-84216.5) <br /> SEE INSTRUCTIONS ON REVERSE <br /> Type or print in ink. <br /> Statement covers period Date of electian if appiicabte: <br /> )"')e/ /O� (Manth, Day,Year) <br /> from �� � <br /> through o <br /> 1. Type of Recipient Committe�: AII Committees—Compiete Parts 7,2,3,and 4. <br /> ❑ Officeholder,Candidate ControUed Committee <br /> Q State Candidate Efection Committee <br /> Q Recall <br /> (Atso Complete Pan 5) <br /> (�General Purpose Committee <br /> (J Sponsored <br /> Q SmaU Co�tributor Committee <br /> Q Political Parly/Centret Committee <br /> ❑ P�imarily Formed Ballot Measure <br /> Committee <br /> Q Controiled <br /> � Spansored <br /> (Also Complete PaR 6) <br /> [j Prnnarily Formed Candidate! <br /> Officeholder Committee <br /> (Atso Complete Part� <br /> 3. Committee lnformation ��•D. NUMBER <br /> COMMITTEE NAME(OR CANDIDATE'S NAME IF NO COMMITTEE) <br /> . �..� �� <br /> rt�ev��.s o� ��ec�c��. � <br /> � <br /> � <br /> STREET ADDRESS(NO P.O.BOX) <br /> '�175 J� � <br /> CITY/� _ , STATE ZIP CODE AREA CODE/PMONE <br /> Date Stamp <br /> s � � <br /> i �� _ � <br /> �` <br /> � � <br /> � � :m._ <br /> 2. Type of Statement: <br /> ❑ Preelection Statement <br /> [j�Semi-annuai Statement <br /> ❑ Terminafion Statement <br /> (Also file a Form 410 Termination) <br /> ❑ Amendmen#(Explain below) <br /> Treasurer(s) <br /> COVER PAGE <br /> ..�� �_ <br /> ;��e of <br /> ''� For Officiel tJse Only <br /> ❑ Quarterly Statement <br /> ❑ Special Odd-Year Repo�t <br /> ❑ Suppiemental Preelection <br /> Statement-Attach Form 495 <br /> ���- � ����-� -- <br /> �� ..�.rr� -��n nnnr ADCA �nnGiaunNlF <br /> ��30 1�l cl�rn 5�r'��z� <br /> CITY .n . _ „ � STATE Z!P CODE AREA CODE/PHONE <br /> OPTlO1�AL: FAX/E-MAIL <br /> 61�1�ti <br /> 4. Verification <br /> I have used all reasonable diligence in preparing and reviewing this statement and ta the best af my icnowledge the infarmation contained herein and in the attached schedules is true and complete. 1 certify <br /> under penalty of perjury under the laws of the State of Cafifornia that the foregoing is true artd correct. <br /> Executed on �+_���u��'`��`�"--�-- By Signature of Treas r or Assistant Treasurer <br /> Executed on <br /> DaEe <br /> Exc�uted ort <br /> Da�e <br /> Executed on <br /> Date <br /> By <br /> Slgneture of CoritroNing Officeholder,Candidate,State Measure ProPonent or Responslble pfficer of Sponsor <br /> $y Signeture of ControNing Officehotder,Canddate,51ate Measure Proponent <br /> By <br /> Signeture otControlling Utficeholder,Cenddate,State Measure Proponent FPPC Form 460(January/05) <br /> FPPC Toll-Free Hetpline:866/ASK-FPPC(866JZ75-3772) <br /> State of Califomfa <br />