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~fficeholder, Candidate, Type or Print in ink. ......... Slatemefll cov.~ period~ ~[~YE~ [ ..... **4 .. u <br /> and Controlled Committee ~//* <br /> ,to. <br /> Campaign Statement -- Long Form <br /> <br /> SEE INSTRUCTIONS ON REVERSE through ./;~/ Page <br /> C~ck o~ of I~ followl~ boxe~ lo Indicate t~ type of slal~nl being filed: Date of Election A F~ Official Use Only <br /> ~ Pm-electi~ Stalem~t If applicable: <br /> ~ ~pple~ntal Pre-elecli~ Slatemenl (Attach a completed Form 495 to Ibis stalem~l.) (Month. Day. Year) <br /> ~ Semi-annual Slal~enl <br /> ~ Terra,alan Slat~ent (Altach a c~plet~ ~rm 415 to Ibis stal~ent.) <br /> <br /> I Oflice~lder, Candidate, II Other Com~ttees Not I~luded in this State~nt: Lb~ ~y o~,r <br /> and Controlled Committee c~i,.,~ ~ i~l~ed ~ ~ c~olidmed $lme~m ~ ~e comrol~d <br /> Incl~ed in this State.hr c~i,~,~ o/w~ck ~, ~ ~iedg~ ~ nr~ pri~ily /~d ~o r~c~iv~ c~rib,~io~ or <br /> ~ ~F~. ~ C~E: to ~ ~e~itures on be~ o/ your c~ida~. <br /> <br /> ~: II~ R f ~E) <br /> <br /> CITY STATE l~ ' -- ~BC~~ C~ITIEE~E~: <br /> C~E ~ - m~ CITY STALE ~ ~ <br /> C~EE ~E~: - (~ ~D~RE~) <br /> <br /> CITY - ~ATE - ' ~ T~R: C~I~DC~EE? <br /> ~~ zmP ~ <br /> C~EE ~E~: (~. ~ ST~) <br /> <br /> ~Nt ~E~ ~ l~R:_ (~ ~1. c~tY STATE ~ ~ <br /> <br /> Attach add~io~l ~or~ on ~proprimely ~1~ c~i~i~ s~ets. <br /> <br /> Ill verification Officeholder or Candidate: <br /> TreamJrm: ! have used all reasonable diligence and to thc hcst of my knowledge thc tTcasurer has <br /> ! have used ali reasonable diligence in preparing this statement and to thc best of my used all reasonable diligence in preparing this statement. ) have reviewed thc stale- <br /> knowledge thc information contained herein and in thc auachcd schedules is uuc and mcnt and to thc best of my knowledge thc information contained herein and in thc <br /> com@lcle. ] ccrdfy under penalty of perjury under thc laws of thc Stale of California attached schedules is truc and complete. I ccrtdy under penally of perjury under thc <br /> that Ihe foregoing is mm and co.ccl, laws of thc State of California thai thc f;oregoing/o//~ is _tn~ and correct. <br /> Execumd on ~t, Al City A~O State Execule. on <br /> <br />) By SICd%IATURE OF TREASURER ' OF OFFC <br /> <br /> FOR INE~MA11ON REQUIRED TO BE PFIOVlD[P TO Y~XJ PURSUANT TO THE INFC~RMATION PRACTICES AC T OF 1911. SEE INFC~MATION <br /> State of Cafilomi~ Fair Polilical Praclice~ Commi~;ion. <br /> <br /> <br />