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RECIPIENT COMMITTEE <br /> Recipient Committee WHERE TO FILE: STATEMENT OF TERMINATION ~"'-..~ <br /> Statement of Term i nation Fi~e original and one copy of this form with: Date Stamp <br /> <br /> Secretary of State <br />This form must be completed by recipient committees Poht,cal Reform D,vis,on <br />that are eligible to terminate pursuant to Government P 0 Box 1467 ~ ~] For Off~,al U~e Only <br /> <br /> Type or print in ink. And, if applicable, file one copy of this form with: F <br /> The c~ty or county ofhcer, if any, who receives the <br /> comm~ee's campaign d,sclosure statements. <br /> <br />I Recipient Committee Information II Treasurerlnform :t~ ~I~CLERK <br /> NAME OF COMMITTEE~ ~ .~ ~g~/ ll.D. NUMBER NAME OF TREASURER <br /> ~ ~/-~t~/~/:~: ~ i~I~:~' J~J <br /> <br /> - MAILING ADDRESS OF TREASURER NO. AND STREET <br /> <br /> AREAEODE/DAYTIME PHONE NUMBER <br /> ~ ~"~ ~ ~ :~ _. ¢_ / III Effective Date of Termination <br /> <br /> DATE FILING OBLIGATIONS WERE COMPLETED <br /> <br />IV Varification <br /> <br /> A. This committee has ceased to receive contributions and make expenditures; <br /> <br /> B. This committee does not anticipate receiving contributions or making expenditures in the future; <br /> <br /> C. This committee has eliminated or declares that it has no intention or ability to discharge all debts, loans received, and other obligations; <br /> <br /> D. This committee has no surplus funds; and <br /> <br /> E. This committee has 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 ar)el to t,~le best~ of my know edge the information contained <br /> herein is true and comple:e. I certify under penalty of perjury under the laws of the State of Cali,f'a'rnie~that,.thi~ ~oregoing is true and correct. <br /> <br /> DAlE ~ CIIY~NDSIAIE _11 I~ .1~ {~.f ~ I1 / <br /> <br /> __ ~,/ .~ ~ ' ~i~NAIU~ OF~O~I~ ~L~F~IC~HOtDER CANDIDAIE OR STATE ME~SUR[ <br /> <br /> t,,, ORMAl ION R, OUIR[D lO B, PROVIOE D 'O YOU PURSUANT ,O ,Hi IN, ORMA,ION P~C, I[[~ AC] OF 191 l. Si[ I,,,ORMATION MANUAL ON CAMP~ DISCLOSURE PROVI~IO,~ O, ~.~'~O[,IICA[ REFORM <br /> State of California Fair Politi(al Pta(ti(es Commission <br /> <br /> <br />