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SHORTFORM <br /> ' Recipient Committee rype or print�n ink. � - � � ' <br /> Campaign S#atement—Short Form � ��������� •' <br /> • SEE INSTRUCTIONS ON REVERSE g��g ��pygrg pgfipd Dat9 Of 61eCt1011 i 8ppliCable: Page� Of ` <br /> For use by recipient committees that heve not received a �,om ) � �p 1 � (Month,Day Year) ��L � 1 2013 <br /> For Ofidel Use Ony <br /> conVibution or other receipt thet must be itemized,have not <br /> recetved or made loans,and have no outatanding accrued 6 � � � 3 �E- �_=;�-��,tia�,���:,°;'„TY <br /> expenaes. through � <br /> 1. Type of Recipient Committee: 2. Type o ��"��-" <br /> p Ballot Measure Cammittee [v�0enerai Pu�pd�e Committee Q �'re-elecdon Statemetyt ❑ Quarteriy Statement <br /> p Primarily Formed O Sponsored , (�Semi-annual Statement Q Special Odd-year Report <br /> p Controlled O Small Contributor Committee ❑ Termination Statement ❑ Supplemental Pre-election <br /> Q Sponsored � Statemerit-Attach Form 485 <br /> p Prima�ily Formed Candidatel ❑ Amendment(Explain) ' <br /> Otficehotde�Committee (n�so cnedc�y�e orsmtemeM you are emencnn9> <br /> I.D.NUMBER Treasurer(s) <br /> 3. Committee Information Z 6 6 8 " <br /> w � <br /> COMMITTEE NAME 1e N�,�Q a-�/n,�v �ed d y <br /> U« v� <br /> 1l('PJV�tS Q� 6�c� C.� � �'C_- ^����S ess� S��n� <br /> 1 �'�.k:� <br /> STREETADDRESS(NO P.O.B0� CITY STATE ZIP CODE AREA CODE/PHONE <br /> a7 5 � 5�-� ���d �� c�4 �yo�-� �s��.3����z� <br /> STATE ZIP COOE AREA CODE/PHONE NAME OF ASSISTANT TREASURER,IF ANY <br /> �e�r� Cr ' c `�oG�3 -3�n - � C��u� v� v fl�e- �'c�v� . <br /> MAIUNG ADDR6S&(IF DIFFERE NO.AND STREET OR P.O.BOX MAIUNG ADDRE 3� <br /> 3 3 0 0�[�e� Sfr.e e.-�. <br /> ��Ty 3TATE ZIP CODE AREA CODEIPHONE 017Y ��v� C! STATE 21P CODE AREA CODEIPHONE <br /> �C�, -�-i r,�4 9yor 3 (o5a 3ro �-9Z�y <br /> OPTIONAL: FAX/E-MAiL ADDRE83 OPTIONAL: FAX/E-MAII ADDRE <br /> 4.Verification � <br /> I have used all reasonable dliigence in preparing and reviewing this statement a�d to the best of my knowledge tt�e fnformatlon cor�tained herein is true and complete. I ce�tiy <br /> under penalty of perJury under the laws of the State of Cal(fornia that the foregoing s t e and corred. <br /> � Executed on �� 3�` ?it)!,�j . gy <br /> DATE SIONATUREOF SURERORASSISTANTTRE=ASURER <br /> B <br /> EX8CUi8d 011 DATE y 81(iNATURE OF GONTROLLIN(i OFFICEHOLDER,CANDIOATE,STATE MEA&URE PROPONENT,OR RESPONSIBLE OFfICER OF&PONSOR <br /> EX8CUt8CI 0�1 BY <br /> DATE SI6NATURE OF CONTROLLiNO OfFICEHOLDER,CANCIDATE,S7ATEMFASURE PROPONENT <br /> Executed on By <br /> DATE SIONATURE OF CONTROLlINO OPFICEHOLDEit,CANDIDATE,STATE MEA8URE PROPONENT <br /> FPPC Form 450(January/06) <br /> � FPPC Toll-Free.Hetpiine:866/ASK-FPPC(8681275-37'f2) <br />