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Recip�ent Commitfiee <br /> Campargn St�fement <br /> Gover Page <br /> (Govemment Code 5ections 84200-84216.5) <br /> SEE INSTRUCTIONS ON REVERSE <br /> Type or print in ink. <br /> Statement covers period <br /> from ��j �� <br /> thro�gh ��� <br /> '�. Type of Recipient Committee: Atl Committees-Complete Parts 1,2,3,a�d 4. <br /> ❑ Oificehoider,Candidate Controlled Committee ❑ Primarily Formed Baitot Measure <br /> Q State Candidate Election Committee Commi#tee <br /> � RE��� Q Gontroiled <br /> (A1so Camplete Part S) Q Sponsored <br /> (Afsa Comptete PaR 6) <br /> �Generai Purpose Committee <br /> Q Sponsored [] Primarily Formed Candidatei <br /> Q Small Contnbutor Committee �fficehotder Committee <br /> Q Political Party/Central Cammittee l�so Compfete Part 7) <br /> 3. Committee Information <br /> COMMITTEE IVAME(OR CANDIDAI'�'S NAME IF NO <br /> I.D. NUMBER <br /> . � � �I' r+ ' <br /> % j <br /> STREET AODRESS (NO P.O. BOX) <br /> �� �� <br /> CiiY „ _ _ . STATE ZIP CQAE t AREA CODElPHONE <br /> t�PTiONAL: FAX!E-MA1L <br /> ��_ �- � �- <br /> EC � � <br /> i ` � <br /> � ; I - t t <br /> .�.. <br /> Date af election if appiic H!�' <br /> (Month: Day,Year) �.�QC <br /> 2. Type of Statement: <br /> ❑ Preelection 5tatement <br /> [�°'�Semi-annual Statement <br /> ❑ Termination Statement <br /> (Aiso file a Form 410 Termination) <br /> ❑ Amendment(Expiain below) <br /> Treasurer(s) <br /> �:� <br /> Gi7Y <br /> COVER PAGE <br /> Page -� of� <br /> For Officia! Use Oniy <br /> ❑ Quarteriy Statement <br /> ❑ Special Odd-Yea�Report <br /> ❑ Suppiemental Preelection <br /> Statement-Attach Form 495 <br /> MAILING ADDRESS �y " <br /> .�.��.�i� 1rG � •~ <br /> � <br /> � r��� <br /> CiiY/1 . . _ , STATE ZIP CODE AREA CODE/PHQNE <br /> (�-W�?���.�:. s���U� <br /> MAILMG ADDRESS � <br /> '��3� �-�,��GI ����� <br /> CITY ,�, k 5TATE ZIP CODE AREA CODE/PHQNE <br /> OPTIONAI: FAX I E-MAIL <br /> ��� <br /> - - .,� .�...�..�.�. <br /> 4a Verification <br /> 1 have used al!reasonable diligence in preparing and reviewing this statement and ta the best of my knowledge the informaGan contained herein and in the attached schedules is true and complete. 1 certify <br /> under Qenalty of perjury under the faws of ihe State of Cafifornia that the foregoing is true and correct. <br /> � .�� �� r <br /> Executed on �Y <br /> Dafe ignatureotTreasure orAssistantTreasurer <br /> Executed on <br /> Date <br /> Executed on <br /> Date <br /> Executed on <br /> Daie <br /> By <br /> Sh�nature oi Controt4ing Oficeholder,Candidate,State Measure Proponent or Responsible Otficer ot Sponsor <br /> �Y Signature oi Controlling Utficeholder,Canckciate,State Measure Proponent <br /> By <br /> Signaiure otContralling Otficehoider,Canc�date,State Measure Proponent FPPC Fortn 460(JBnu8ry/05) <br /> FPPC ToH-Free Helpline:866tASK-FPPC(866/275-3772) <br /> State af California <br />