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OFFICEHOLDER AND CANDIDATE <br />Officeholder and Candidate STATEMENT OF TERMINATION <br />Statement of Termination D,te Stamp <br />This form must be completed by officeholders and WHERE TQ FILE: <br />candidates that are eligible to terminate pursuant Officeholders and candidates must file <br />to Government Code Section 84214. Form 416 with the filing officer with <br /> whom they filed their original campai, ~ 2 6 ~ <br /> Type o~ print in ink. statements (Form 470 or 490). <br /> <br />I Officeholder or Candidate Termination II Office Sought <br /> NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD FOR WHICH YOU ARE FILING THIS STATEMENT <br /> <br /> RESIDENTIA~ OR BUSINESS ADDRE$~ ~. AND STREET JURISDIETION (IF APPLI~BLE) <br /> STATE ZIPCODE ~*~O~ ~'~/ ~'r. IDISTRI~NUMBER(IFAPPLI~BLE) <br /> ~ ~o~ ~1~ ~ ~o~ III Effective Date of Termination <br /> AREA CODE~AYTIME PHONE NUMBER DATE FiLiNG OBLIGATIONS WERE COMPLETED <br /> <br />IV Verification ' <br /> For the office listed in Part II of this form, I verify that: <br /> <br /> A. I do not hold or am no longer a candidate for the office; <br /> B. I have ceased to receive contributions and make expenditures; <br /> C. I do not anticipate receiving contributions or making expenditures in the future; <br /> <br /> D. I have eliminated or I declare that I have no intention or ability to discharge all debts, lo <br /> have no surplus campaign funds; and <br /> F. I have filed all campaign statements required by the Political Reform Act disclosing all reportable transactions. <br /> <br /> I have used all reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the information contained <br /> herein is true and complete. ~certifyunderpena~ty~fperjuryunderthe~aws~ftheState~fca~if~miathattbef~reg~ingistrueandc~rrect. <br /> <br /> o.,, . <br /> <br /> State of Califmnia Fair Political Practices Commission <br /> <br /> <br />