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officeholder, Candidate, Ty~o, print in Ink. COVER PAGE- LONG FORM <br />, Statement cov~s period Date Stamp <br /> and Controlled Committee ~ ,? (~,~:/..,~ <br /> Campaign Statement -- Long Form ,om - - · <br /> (GovemmentC~eSe~ons842~-84216 5) ~ . ~ ' - ~ <br /> SEE INSTRUCTIONS ON REVERSE th~°ugh~ / ~-( ~' ~ <br /> ~ck one of the fol~wing ~xes to i~icite the ty~ of statement ~ing filed: Date of eb~ion U ap~lca~: Fo~ Official Use Only <br /> (~th, Oly, Yei~) -- <br /> ~ P,e~ie.ion Statement-- <br /> Supplemental P,e-ele~lon Statement (A~ich, completed Form 495 to this statement ) ,' ~ I 2 <br /> Jlrmi~ltlO~ Slltlme~l (A~ich l completed Form 415 to Ibis itlllme~t.J <br /> <br /> Include iii Statement c~m~eeJ ~1 ~l~d in 1~ c~MMaled.alemen( you a~ any <br /> (~m~eeJ of w~h you ~ve k~wle~e (hal ale <br /> NAME Of ~F~EHO~ER OR ~ND~ATE <br /> <br /> ~gOlCaL ~ IU~NESS ADD. SS ~O A~ Sl~J~ ~J ~ T~AS~R C~IR~LED <br /> STAll ZJ C~ AMA C~AYTNi ~ ~ ~ lJJl C~lA~ LID C~M~ll <br /> <br /> I h~vt uad ~11 ~ea~nlble diligence in p~pl~ing th~ ~latement I h~ve ~evitwed th~ itltemtnt ~nd to the Nfl pt ml~le~e ~ lion conlmned herein <br /> <br /> fOR INI~AIION ~lUO JO IJ PROVIDED TO IOU PURSUANt JO IHJ INIO~AI~N P~ICJS ACl PI Iii?. SJJ INFORMAIION MANUAJ ~AMPAI~N OlSCtObuaJ FROVtSI~N ~_~ P~J!iKA~ <br /> <br /> <br />