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Amendment to Type or Print in Ink Campaign Disclosure Statement This form must be used io amend slat°merits filed pursuant to Government Code Sections 84200_84216.5, and must beale Jl~ 5 oo~'gZ [ .~, For Otlicial Uso Only I filed with all filing officers who received the statement being amended. NOTE: Do not use this form to amend a Statement of Organization, Form 410, Candidate Intention, Form 501, or a Campaign Bank Accounl, Form 502. Use Ih° actual Form 410, 501 or 502, respeclively, to make amendments. The information required in Part ! must correspond to the information provided on the campaign statement, I Hame el Filer (See important information on reverse) II Amendment Ifllormalion NAUE OF FILER: I.D. NUaaBER IIF APPLICARLEI A Tho following inlormalion amends campaign disclosure slatemonl, Form No. ORES FILER: ~ (, . ,~O S ~[~l[ffT) B. Tho amended information affecls items on Ih°: c:X--- 4%_. [] ovo.,.a0. [] C~T¥ STATE ZIP COD£ [] Schedule{a) C.~ [] AREA CODEfOAYIIME PIIONE NUMBER - your official campaign slalomonl. PI~,~s~ illech i coyer ~$gl, lUll~m&l~ ~igo Nndlot ~pp~opHel~ schedule{s) Io Ihl$ I:o~m 405 It n~$$,,r¥ lot c, lefllle~llon. Include addilio~al inlormalion on appropdalel¥ labeled continuation shools. NAME OF TREASUFIEN IF RECIPIENT COIdMITTEE: (NumboT of sheels allached ) PERMANENT ADDRESS OF TREASURER: (IF APPLICABle) (NO. ANI STREET) CITY STATE ZIP CODE AREA CODE/DAYTIME PI, lONE NUMBER III Verification (See important information on reverse) I have used all reasonable diligence in prepaiing this statement. I have reviewed thc statcmcnt and to thc best of my knowledge thc information contained herein and in thc attached schedules is truc and complete. I certify under penalty of perjury undeT thc laws of thc State of California that thc foregoing is truc and corrcct. Officeholder, candidate, stale measure proponent, or sponsored commillee I officer ficall all r best of my' ' ' : ' ' knowledge tho treasurer has used all reasonable diligence in preparing this slalement. I have reviewed tho slalement and !o the best of my knowledge the information contained herein is true and complete. I certify under penally of perjury under Ihe laws of the Slate of California that the foregoing is true and correct. gxoculod on Al By DAlE CITY AND SlAI£ SlGNAIUI~ et: OFFICEHOLDER. CANOIDAI£. PROPO~NI. OR 1~SPONSIBLE O~cFIC~R gXOCUlOd on Al By DAle CiTY AND SI'ATE SIGNAIURE OF OFFICEHOEDER. CANDIDAIE. OR Pnc)PC)NENI , Executed on At By ~ DATE CIIY AND STALE SIGNAIURE OF OFFICEI IO[ DER. CANDIDATE. OR PROPONENT FOR INFORMATION REQUIRED TO BE PROVIDED TO YOU PURSUANT TO THE INFORMATION PRACTICES ACT OF 1977. SEE INFORMATION MANUAL ON CAMPAIGN DIsc~p_~~ POLIIICAL REFORM ACT. Stata of Calllornla Fair Pollll¢&l Pra¢licea Commission.