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,, ~G E~,,~ E0 I ~)N~; i¥)RM Officeholder, Candidate, Typo or P.nt In Ink. ........... Statement cove. period ~,' .: and Controlled Committee Campaign Statement -- Long Form from / SEE INSTRUCTIONS ON REVERSE ~0 ?~ Page__ C~ck o~ ol t~ followi~ boxee to Indicate ~ ty~ of etal~nt bel~ filed: A F~ Official U~ ~ Pre-elecli~ Stal~t If applicable: pple~ntal Pm-electi~ Slatement (Attach a completed Form 495 to Ibis slalem~t ) (M~nth, Day, Year) mi-annual Slal~en, ~/Z~ 1 ~ ~ Term~al~n Slal~enl (Allach a c~plet~ ~rm 415 lo Ihis slat~enl.) . and Controlled Committee c~itlees ~t i~l~ed ~ th~ c~oIMated st~e~ t~ ~t co~rol~d by you a~ ~y Included in this Statea. I c~itlees of w~ch you ~ ~ledge that are pri~iO f~d to receive c~ributio~ or ~ ~ ~n ~ c~: to ~ ~e~itures on be~ofyour c~ida~. ~~~ C~I[IEE ~ I O C~I~EE ~E~: (~ ~ SLED) Attach ~d~iolI ~or~n on ~propri~ely ~i~ comi~i~ s~ets. III Verification Officeholder or Candidate: Treasure~: I have used aU reasonable diligence and Io the best of my knowledge thc n'casurcr has ! have used all reasonable diligence in preparing this stalcmcm and to thc best of my used all reasonable diligence in preparing this statement. ! have reviewed thc slam* knowledge thc information contained herein and in thc auachcd schedules is Iruc and mcnt and to thc best of my knowledge thc information contained herein and in thc complete. ! certify under penalty of perjury under thc laws of thc Slam of California attached schedules is truc and complete. I certify under penalty of perjury under thc that thc foregoing is true and correct, laws of thc State of California that thc foregoing is tree and correct. TAlE By DATE ~' cTrY ANO STATE//' ' FOR INFORIvlAilON REQUIRED TO BE PROVIDED 10 YOU PURSUANT 10 IHE INFORMATION PRACTICES AC ! OF 1971. SEE INFORMATION MANUAL ON CAIVlP~LGH DISCLOSURE PROVISIONS OF THE POi Stato of Calilornla Fair Political Practices Commission.