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Officeholder, Candidate, Type or print in ink. COVER PAGE- LONG FORM <br />and Controlled Committee Statement covers period Date Stamp <br />Campaign Statement -- Long Form from ~ <br />(Government Code Sections 84200-84216.5) through '~ / <br />SEE INSTRUCTIONS ON REVERSE <br />Check one of the following boxes to indicate the type of statement being filed: Date of election if applicable: <br /> B Pre-electionStatement (Month, Day, Year) NOV 2 0 I!JL.. For Official Use Only <br /> Supplemental Pre-election Statement (Attach a completed Form 495 to this statement.) <br /> Special Odd-Yeer Campaign Report ~ 7/?>..~ <br /> Semi-annual Statement // ) <br /> Termination Statement (Attach i completed Fo~m 415 to this statement.) <br /> to, List any other <br /> Inclu¢ lis Statement committees not induded in this consolidated statement that are controlled by you and eny <br /> coma/trees of which you have knowledge that ere primarily formed to receive contr/but/om <br /> NAME OF OFFICEHOLDER OR CAIdDIDATE <br /> [/~/~//t/ ~ /~P/~/ ' ortomake ex. ndi~uresonbehalfofyourcandtda.. <br /> I <br /> COMMITTEE NAME <br /> OFFICE ~OUGHT (~ HEU~ (INCLUD~ LOCATIO~ AND DISTRICT NUMBER If AII~LICAILE) I I.D. NUMBER <br /> <br /> C~Y STATE ZIP CODE AREA C~AYTIME PHONE COMMnTEE ADDRESS (NO. AND STI~ET) <br /> <br /> COMMITTEE NAME I I,O. NUMBER <br /> i AND STBEET) <br /> I <br /> £C~Y STATE ~1~ CODE AREA CODEIDAYTIME PHONE NAME OF TREASU~E~ CONT~OLIE~ COMMItteE? <br /> <br /> NAME OF, TREASURER/ . COeAMmEE REX)~SS e~O. AND STREEt1 <br /> II~RMANENT ADoaEss OF TREASURER (NO. AND STREET) C/TY STATE ZiP CODE AREA COOf.)OAYTIME PHON~ <br /> ~dl~¥ STATE ~ C~ ~ <br /> <br />III Verification <br /> <br /> true end complete. I certi~ under penalty of I~_ rjury under the laws of t__hl~,~tato of California that the foregoing <br /> <br /> DATE CITY AND STATE / ,.// SIGNATURE OF TREASURER <br /> An officeholder or candklete who controls I committee must also verify the campaign statement. I have used all reasonab~ diligence ~ to the best of my knowledge the treasurer has used all <br /> reasonable diligence in preparing this statement. I hive reviewed the statement and to the best of my k nowledge/t~e infg~J~ Btigp'c~, rained herein and in the attached schedules is true and <br /> complete. I certify under,penalty of perjury under the laws of the State of California that the foregoing is true an d ~orreo~./~ ' <br /> <br /> DATE; / / CflY AND STATE / -// ~/~ ' h~/: LeiG~I~TURE OF CANDIDATE/OFFICEHOtDER <br /> DAlE //CITY AND STATE ' ' ' 'SI/G~/,A1'URE OF CANDIDATE/OFFICEHOLDER <br /> FORINFORMATIONREOUIREDTOBEPROVIDEDTOYOUPURSUANTTOTHEINFORMATIONPRACTICESACIOF 1977, SEEINFORMAIIONMAN~ tN CAMPAIGN DI$CtOSURE PROV~C)N$OF THEPOLIIICAt REEORMAC1 <br /> <br /> <br />