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OFFICEHOLDER AND CANDIDATE <br /> STATEMENT OF TERMINATION <br />Officeholder and Candidate <br />Statement of Termination <br />This form must be completed by officeholders and WHERE TO FILE: ~-. <br />candidates that are eligible to terminate pursuant Officeholders and candidates must fih~ ,: For Official U~ Only <br />to Government Code Section ~214. Form 416 with the filing officer with NOV <br /> whom they filed their original campai <br /> Ty~ Or print in ink. statements (Form 470 or 4901. <br /> <br />I Officeholder or Candidate Termination II Office Sought or Held <br /> NAME OF OFF~EHOLDER OR ~ND~ATE OFF~E SOUGHT OR HELD FOR WH~H YOU ARE FILING THIS STATEMENT <br /> <br /> RESIDENTIAL OR BUSINESS ADDRESS ~. AND STREET JURISDICTION elf APPLICABLE) m DISTRICT NUMBER (IF APPLICABLE) <br /> I <br /> . <br /> CITY STATE ZIP CODE <br /> ~Y ga ~c~ ~XZ, ~ e~ ~// mmm Effective Date of Termination <br /> /~REA CODE~AYTIME~HONE NUMBER DATE FILING OBLIGATIONS WERE COMPLETED <br /> <br />IV Verification ' <br /> <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 /> <br /> B. I have ceased to receive contributions and make expenditures; <br /> <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 ali debts, loans received, and other obligations; <br /> E. I 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 /> fOR INFORMATION REOUII~D 10 ~[ PROVIDED ID YOU PURSUANI 10 THE INFORMAIION PRACTICES AC! OF 1917, SEE INf ORMAIION MANUAl. ON CAMPAIGN DISCLOSyRE PROVISIONS Of THE POLITICAL REFORM lCl~ <br /> <br /> State of Califomi& Fair Political Pratiices Commission <br /> <br /> <br />