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OFFICEHOLDER AND CANDIDATE <br />Officeholder and Candidate STATEMENT OF TERMINATION <br />Statement of Termination Date Stamp <br /> <br />This form must be completed by officeholders and WHERE TO 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 campaign F~J~ ! ~ ~ <br /> Type m print in ink. statements (Form 470 or 490). <br /> <br />I Officeholder or Candidate Termination II Office Soughtol <br /> NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD FOR WHICH YOU ARE FILING THIS STATEMENT <br /> <br /> S DE L O BUSINESS ADDRESS NO. AND STREET JURISDICTION (IF APPLICABLE) <br /> <br /> CITY STATE ZIP CODE <br /> ~[~Y0 ~ c){ d*~/~/~ d ~ ~ D ~ / III Effective Date of Termination <br /> <br /> AREA CODE~AYTIM~HONE 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 (andidate for the office; <br /> <br /> B. I have ceased to receive (ontributions 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 all debts, loans received, and other obligations; <br /> <br /> E. I have no surplus campaign funds; and <br /> <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 _o~f my knowledge the information contained <br /> herein is true and complete. I certify under penalty of perjury under the laws of the State of California tl~t th~ fOregoing is true and correct. <br /> <br /> Executed on / <br /> 7 DATE CITY ANI~ SLATE A /OF OFFICEHOLDER OR CANDIDATE <br /> <br /> FOR INF ORMAIlON REOUIR~D 10 BE PROVIDED TO YOU PURSUANT TO 1HE INFORMATION PRACTICES AC1 OF 1977, S~ E INf ORMAIION MANVAL ON CAMPAIGN DISCLOSyR~ PROVISIONS OF THE POLIticAL R£FORM ACT <br /> <br /> State of California Fait Political Practices Commission <br /> <br /> <br />