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RECIPIENT COMMITTEE <br />a ;n; ,,,ec,~,,en, Corn mittee WHERE TO FILE: STATEMENT OF TERMINATION <br />Statement of Termination FileoriginalandoneEopyofthisformwith: <br />thatThis formate eligiblemUSt betoCOmpletedtermi by recipient committees Secretary of State <br /> Political Reform Division <br /> hate <br /> pursuant <br /> to <br /> Government <br /> ' ~ ] ~ I/ JJ ~For Official Use Only <br /> Code Section 84214. P.O. Box 1467 <br /> <br /> The city or county of ricer, if any, who receives th, <br /> commiffee's ca m paign disclosure ~atemen~. . crry CLERK I I <br />I Recipient Committee lnformation II Treasurerlnformation <br /> <br /> ' MAILING ADDRESS OF TREASURER NO,AND STREET <br /> ADDRESS OF COMMITTEE ND.AND STREET <br /> /~ 7~ ~ ~ CITY / STATE ZIP CODE <br /> <br /> ~b~ ~ ~ ~ AREA CODE~AYTIME PHONE NUMBER <br /> <br /> ~/~) ~ ~-/~ III Effective Date of Termination <br /> DATE FILING OBLIGATIONS WERE COMPLETED <br /> <br />IV Verification <br /> A. Thi~ committee ha~ ceased to receive contributlon, and make expenditure,; <br /> 8' lhi* r°mmitt~ do~ not anfidpat~ r~ivin~ ~ontribufion~ or makin~ ~xp~nditure, in th~ futur~; <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 /> D. This committee has no surplus funds; and <br /> E. This committee has filed all campaign statements required by the Political Reform Act disclosing all repo~able transactions. <br /> <br /> ~have used all reasonable dil gence in preparing th s statement. I have reviewed the statement and to the best of my knowledge the information conta ned <br /> erein is true and complete. I ce~ify under penalty of p~rju~ under the laws of the State of Cal~rnia that the~regoing is true and (orre~. <br /> <br /> f / GATE Cl~Y ~DIS?ATE . <br /> <br /> Executed on At 8y <br /> DATE CITY AND STATE <br /> SIGNATURE OF CONTROLLING OCFICEHOLDE~ ~NDIDATE. OR STALE MEASURE PROPONENT <br /> Executed on At <br /> <br /> State of Callfmnla Fair Politi(al Pre(rices Commission <br /> <br /> <br />