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0!TY CLERK DEPARTH, ENT ION(; F()RM ' <br /> Officeholder, Candidate, Type or Print In Ink. Statement cove. period <br /> and Controlled Committee <br /> // / <br /> Campaign Statement -- Long Form from <br /> <br /> (Govcmmem Code Sections 84200-84216.5) <br /> SEE INSTRUCTIONS ON REVERSE through /Z/3:t'/~'~' JA~[ Z9 8 05 <br /> <br /> Ch~¢k on~ el Ih~ lollowing boxeo Io indic&lo Ih~ lyp~ el ,,lel~m~.l b®lng Iilod: Dele el [le¢lion A For Official Uso Only <br /> [] Pro-ol0clioo Slalomonl il epplioeblo: <br /> sem pple~nlal Pre-eleclion Slalemenl (Allach a compleled Form 495 to Ihis staleme~l ) (Monlh, Day, Yeer) <br /> i-annual Slalemenl <br /> [] Termina0On Slalemen! (Altach a compleled Form 415 Io Ihis slalement.) 3 <br /> <br /> I Officeholder, Candidate, II Other Committees Not Included in this Statement: List .ny other <br /> and Controlled Committee coo..iuees m~t included in tkis consolidated sMter,~nt IA~ are controlled by you and <br /> Included in this Statement committees of which you have knowledge that are primarily formed to receive contributions or <br /> , n*~ OF, OF~:~::~O[n~R OR cAR~OMI:: to make expenditures on behaO~ofyour candidacy. <br /> <br /> ~IcFICE SOUGHT OR ~i~LD: (INCLUDE LOCATIO# AI,~IjlISII~CI NUMBER F APPLIC, A,.I~LE) <br /> <br /> RES~mNIIAt OR BUSINESS ADDRESS (NO AN~STREEI! NAME OF II~r_ASUI~R: C(~NIRO~U:O COdMIll£E? <br /> CITY SLATE ZIP COD~ ' -' AREA COOF. A~YTIME PTION~ COMMIITEE ADDRESS: (NO AND SIREET ) <br /> <br /> COMMrr1EE NAMe: I I O NLIMSER CIIY STATE ZIP COOi~ AREA COOE/T~AYTIME PHONE <br /> I <br /> <br /> CITY . ? STATE ZiP ~ CONIROLLED COMMfflEE? <br /> COMMffI*EE AOORESS: (NO ANO STREET ) <br /> <br /> PERMANENT A~ClRES~ OF T~R: [NO AN~ SIRED) CITY STATF ~ ~ AREA COEIF. A:IAYTIMI: <br /> co_. <br />! CITY STATE ZIP COOE ' AREA COOI:/DAYIIME <br /> Affm:h ~rMilio~I b'~'orm~ion on ~proprioJeIy l~eIed ¢o~i~io~ sheets. <br /> <br /> III Verilic&lion Officeholder or <br /> Tro-~urm: I have used all reasonable diligence and Io Ibc be, si of my knowledge Ibe lrcasurcr has <br /> ! have used all reasonable diligence in preparing Ibis slalemcm and lo thc best of my used all reasonable diligence in preparing Ibis stalcmefll. I have reviewed Ibc <br /> knowledge Ibc information contained herein and in Ibe altached schedules i~ Irne and mcm and to Ibe besl of my imowledg¢ Ibc infonnalioo contained herein and in <br /> complete. ! certify under penally of ~rjury under Ibe laws of Ibc Stale of California altached schedules is true and ¢omplele. I cerlify under penally of perjury under <br /> Ihal Ibc foregoing is m and ¢orrccL laws of Ibc Stale of.California Ihal Ibc foregoing is trne~and eot'reeL <br /> <br /> 0 R 0 SIGNATURE OF OFFICEHOLdeR CANOOATE <br /> FC~q IHFCXqlV~TION REOUIflED lO BE PROVIDED 10 YOU PUflSU^HI 10 THE INFORM^TtCNd PRACTCES ACT OF 1977. SEE INF(~qMATION MAI~K/^L ~ CAblP~ld DISCLOSURE PFIOVISIC~dS ~ TttE <br /> <br /> SI&lo of Celilornle Fair Polillce! Pra¢li¢os Commi,,'-ion. <br /> <br /> <br />