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I ()NG I-'()RM <br />Officeholder, Candidate, Type or Pdn, ,. ink. <br />and Controlled Committee <br />Campaign Statement -- Long Form <br />(Government Code Scclicms 84200-84216.5) <br />SEE INSTRUCTIONS ON REVERSE <br /> <br /> [~mPlemer~al Pm-eleclu3n Slalemenl (Allach a compleled Fo~m 495 Io Ihi$ slalemenl ) i-annual Slalemenl <br /> [] TeTminaPon Slalemenl (Allach a coo~plMed FoTm 415 Io Ibis $1alemenl.) <br /> <br />I Officeholder, Candidate, II Other Committees Not InCluded in this Statement: List any other <br />and Controlled Committee c~,,~atees not Mcb,ded in t)~ consolidated statewnl tam are comroiled by you and any <br />In¢lnded in this Statement committees of widch yOM have knowledge that are primarily /ormed to receive contributions or <br />n~ OF OFF~C~HOL~R OR CAI/pO~IE: lo make expenditures on beha~ of yOur candidacy. <br /> <br /> OFFICE SOIJGtII~R HEm: (#,ICLUOF LO~_aMION,~() ~ISTRIC;I NUMBER IF .APFLICABLE! <br /> <br /> RESIDENTIAL OR BUSJNEee AI:)~RESS: (NO. AN(~SIREEI¥ - NAME OF IREASL~ER: CONIRCXLEO COMMITTEE7 <br /> CITY STATE ZI~ COOE ~ COOEA~YI'IME IR*lONE COMMIITEE ADOREe~q: (NO ANO SIREE1 ) <br /> <br /> COMMITIEE NAME: I I I D NUMBER CiTY STATE ZIP COOE ~ C~Y11M[ PIK~IE . <br /> I <br /> <br /> co~n0 Am~ss (No ANOSTREET) 0 <br /> <br /> ~TY - - /STATE ' ZIPC~:X~ /ARE. AC(X~YIWE~ liAMEOFI~R: CONIROLLEDCO4~#dlTIEE? <br /> <br /> ~ OF mr~s~eA: ~ celM.ee mmess: (NO ANO stREet) <br /> <br /> PEAMRNENT ,N]I]IEqe OF TRE.4SUIIER: (NO K SIREE1) CITY STATE <br /> <br /> - - / SLATE ZIP COOE 'W CO~EJOAYTIME PHONE <br /> Attach addition! ~ormalion on appropriately labeled continuation sheets. <br /> <br />III Verification Officeholder or Candidate: <br />TroaourM: ! have used all rcasmublc diligcncc and m ~c hcst of my knowledge thc treasurer has <br />!havc uscd all rcasonablc diligence in prcpadng Ibis slalcmem and Io Ibc hcsl of my used all reasonable diligcncc in preparing Ibis slalcmcnt. ! have rcvicwcd Ibc stalc- <br />knowlcdgc Ibc information conlaincd herein and in Ibc aUachcd schcduies is Iruc and mcnt and Io Ibc bcsl of my knowledge Ibc information conlaincd herein and in thc <br />compiclc. I ccrdfy under pcnahy of pcrjury undcr dtc laws of Ibc Stae of California aimchcd schcdulcs is Iruc and complctc. I ccflify undcr penalty of pcrjury undcr thc <br />thai Ibc foregoing is uuc and con'ccL laws of Ibc Slatc of California that thc foregoing is Iruc and concct. <br /> <br /> ~I~TE ~ ' Cil~ AND STATE ' CiTY ,~ STATE <br /> S~TURE _ _. cTHI~OER~ OR C)WDDATE <br /> TREASURER <br /> <br /> FC~ INFC~MATIC~t RE¢~JIRED 110 I~E F~IOVIDED TO YOU PU~ISUAN! lC) IHE INJ:O~MATION PRACTICES AC T OF 1977..~:E II~ORMAIlC~ MANUAL OH C2~IPA!~ C~L~/BI~I~O~C~$ OF ]JIF. EC&J[ICAL Pu~C3Ud AC[ <br /> $1&le ol C&lllor~ia Fair Polilical Pr&¢licee Comnd,~sion. <br /> <br /> <br />