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Recipient Committee COYER PAGE <br /> Campaign Statement Type or print in ink. <br /> Cover Page <br /> (Government Code Sections ~200-84216.5) <br /> State ent covers period Date of election if applicable: JAN 3 0 Z003 / <br /> from ~ J~ (Month, Day, Year) of <br /> <br /> SEE INSTRUCTIONS ON REVERSE through 'V''/~ ~/~ CiTY 0F .E~W00Dc,~ CLE.K For Official Use Only <br /> <br /> t. Type of Recipient Commiffee: All CommiU~s - Complete Pa~ 1, 2, 3, and 4. 2. Type of Statement: <br />  Offi~holder. Candidate Controll~ Commi~ ~ Ballot Measure ~mmi~ee ~ Preelection Statement <br /> O State Candidate Ele~on Commiffee O Pdmaffiy Formed ~Semi-annual Statement ~ QuaHeHYs~cial Odd-YearStatementRepo~ <br /> O Re~ll O ConEolled ~ Te~inaaon Statement <br /> ~tePa~5) O S~nsored ~ SupplementalPreelection <br /> <br /> ~ General Pur~seCommittee (Al~m~etePa~) ~ Amendment (Explain below) Statement - A~ach Form 495 <br /> O Sponsored ~ PrimarilyFormedCandidate/ <br /> O Small Con~butor CommiEee Officeholder CommiEee <br /> O Polifi~l Pa~/~ntral ~mmffiee (Al~tePa~7) <br /> <br /> 3. Commiffee Information I,,~. NUMBE~ ~ ~ Treasurer(s) <br /> <br /> STREET ADDRESS (NO P.O. BOX) ~~ ' <br /> <br /> CITY ~ ~ ~ -- ~ STA~ ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY <br /> <br /> MAILING ADDRESS (IF DIFFERENT) NO'AND STREET OR P.O. BOX MAILING ADDRESS <br /> ~~ OPTIONAL: FAX / E-MAIL ~DRESS <br /> <br />4. Verification <br /> I have used all rea~nable diligence in preparing and reviewing ~is s~tement and to the best of my kn~ edg~dg~e i~o~e i o ion ~nta ned here n and in the a~a~ed schedules is true and ~mplete. I <br /> <br /> Executed on By <br /> <br /> <br />