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Recipient Committee COVER FAGE <br /> Campaign Statement Type or print in ink. Date Stamp <br /> Cover Page .r-';~ ~ <br /> (Government Code Sections 84200-84216.5) <br /> <br /> fromo, lo, l~_ (Month, Day, Year {,?, JUL3 12002 <br /> j ! I~i For Official Use Only <br /> <br /> SEE INSTRUCTIONS ON REVERSE through~ ~I ~/ [. <br />1. Type of Recipient Committee: All CommJNees- Complete Parls t, 2, 3, and 4. 2. Type of Statement: <br /> ~"~Officeholder, D Measure Committee ['-] Pmelechon Statement <br /> Candidate <br /> Controlled <br /> Committee <br /> Ballot <br /> [] Quarterly Statement <br /> 0 State Candidate Election Committee O Pdmadly Forrnod ~,,.Semi-annual Statement <br /> O Recall 0 Controlled [] Special Odd-Year Report <br /> ~x~oc.~w~P-,,~5) 0 Sponsored [] Termination Statement [] Supplemental Preelecben <br /> tx~o ~ P~ 6) [] Amendment (Explain below) Statement - Attach Form 495 <br /> [] General Puq3ose Committee <br /> O Sponsored [] Primarily Formed Candidate/ <br /> O Small Contabutar Committee Officeholder Committee <br /> O Polilk:al Pady/Central Committee CA~o ~ ~ ;3 <br /> <br />3. Committee Information I''D' NUMe~F::~// ,:~ ~ Treasurer(s) <br /> COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMI~rEE) <br /> <br /> MAILINO ADDRES~ - <br /> <br /> STREET ADDRESS (NO RO. BOX) CITY STATE ZiP CODE AREA CODE/PHONE <br /> CITY ~' ~, ~TA~E ZiP CODF.~ AREA CODE/PHONE NAME OF ASSISTANT TRE^S ER, IF ANY <br /> iT) NO~I~ OR RO. EOX MAILINO ADORESS <br /> <br /> OPTIONAL: FAX / EE-MA~L'A-DORESSv ~ OPTIONAL: FAX I E-MAIL ADDRESS <br /> <br />4. Verification <br />I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowle~ the~n~o~lmation contained herein and in the attached schedules is true and complete. I <br />certify under penalty of perjury under the laws of the State of California that the foregoing is true and corr~ctl ~11/11 <br /> Executed on ~{~~z''~ By ~' ntT <br /> <br /> <br />