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· M:TiCenofaer, t.,ana~aa[e, COVER PAGE- LONG FORM ~andControlled Committee Type or print in ink. Statement cg,vers period Date Slamp (Government Code Sections 84200-84216.5) ~-, SEE INSTRUCTIONSONREVERSE through /~ '/~ --TY ~) ~ ~ Check on~f the following boxes to indicate the type of statement being filed: Dote of election If applicable: ~ ~ ~ - I ~ ~ J ~ ~or Olliclal Use Only ~ Pre-election Stalement (Month, Day, Year} ~ ~' ~ I ~ Supplemenlal Pre-election Statement (Aflach a completed Fo[m 495 to this statement.) -' ~ Special Odd-Year Campaign Repo~ ~ Semi-annualSlatement ~/~ ~ ~ CJTY~}~O~CiTyI ~ Termination Stalemenl (Aaach a completed Form 415 to lhis statement,} I Officeholder, Candidato, and Controlled Committeo II Other Committoe~ ~ot Included in thi~ Stat, merit: Included in this Statement commi~ees not Included in thio consolidated statement that are controlled by you and NAME OF OFFICEHOLDER OR CANDIDATE any committees of which you have knowledge that are primarily formed to receive ~OC~ ~0~ contributionsortomakeexpendlture~onbeh.lfofyourcandidacy. CIT~ -- STATE ~ ZIP COqE -- ~EA CO~EIOAYHME PHONE -- COMMITTEE ADDRESS (NO AND STREET) COMMITTEE NAME ID. NUMBER NAME OF TREASURER PERMANENI ADDRESS~F T~E~SURER (NO AND SIREET) ~~ ~ ~ ~ F~j~:5~, Attach additio.alinformationo~appropriate/ylabolodcontinuationsheets. III Verification I have used all reasonable diligence in preparing {his statement· I have reviewed the statement and to the b~f my knowledge the informe~o~tained herein and in the aHached schedules is true an~ complete. I cedify under penalW el perju~ under the laws of the State of Calil~rnia that the foregoing is tru~ an~r~ct.~ ~ . ~ ~ )~ . An officeholder or candidate who controls a commiffee must also verify the campaign statement. I h~used all reasonable~iligence and lo the best of my knowledge lhe treasurer has used all reasonable diligence in preparing this statement. I have reviewed the stalement and to the best of my knowledge I~nfo~zcontained herein and in the altached schedules is true and complete, I ceHgy under penalty of perju~ under the lawA el the ~te of California that the foregoing is true an~ correcL /~ ~ ~ DATE CI~ AND STATE- ~ - - v - SIGNATURE OF CANDIOAT~OFFICEHO~DER Executed on At By Execuled on At By DATE CI~ AND STATE SIGNATURE OF CANDIDAT~OFFICEHOLOER FOR INFORMATION REQUIRED TO BE PROVIDED TO YOU PURSUANT TO THE INFORMATION PRACTICES ACT OF 1977, SEE IHpORMATION MANUAL ~N CAMPAIGN DISCLOSURE PROyISlONS OF TH~ POLITICAL REFORM ACT State of California Fair Political Practices Commission