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· Officeholder, Candidate, l'¥pe or print in ink. COVER PAGE - LONG FORM <br /> and Controlled Committee statementcoversperiod DateStamp <br /> Campaign Statement -- Long Form flom--~///~/~' <br /> SEE INSTRUCTIONS ON REVERSE through/ i/~ , <br /> Check o~ ~ the foll~ing ~xes to I~icate the ty~ ~ statement ~ing find: Date ~ e~ion ~ applica~: <br />  PreciSion Statement (M~h, Day, Year) For O cial U~ Only <br /> Supplemen~l Pre~l~ion Statement (A~ach a completed Form 495 to this statement.) <br /> ~ S~ial Odd-Year Cam~ign Re~ <br /> <br /> ~ Termination Statement (A~ach ~ completed Form a15 to this statement.) ~iFf <br /> I' Officeholder. Candidate, andControl ed Committee II OtherCommi~ee IotlnCluee~lnmr ,tatement. <br /> Included in this Statement c~m~ees~ti~l~dint~com~Matednate~nt~atarec~trolledbyyoua~a~ <br /> NAME OF OFF~E H~ER OR ~NDID~TE c~es of w~h you ~ve k~e that a~ ~mari~ f~med to receive c~trl~ <br /> <br /> <br /> <br /> III Verifi~tion <br /> I have u~ all reachable diligence in preparing this Katement. I have reviewed the ~atement and to the ~ of my kn~ge the inf~tion con~d herein and in the a~ached sch~ul~ is <br /> true and corn pl~. ) ce~if~ under ~fla~ of ~rjury under the laws of California that the forgoing is true a~ ~re~. .~ <br /> <br /> An officeho~r ~ ~ldate who controls a comm~ee mu~ also ver~ t~ campaign s~teme~. I have used all reachable diligence and to the ~ or--now edge the treasurer has used a I <br /> reachable dilige~ in pre.ring th~s .atement. I have reviewed the statement and to the ~ of my kn~ledge the inVaSion conta~d herei~ in'he a~ach~ schedu es s true and <br /> corn plate. I ce~i~ ~der~na~ of ~rju~ under the laws of the S~te of California that the foregoing is true and corre~. ~ /~ <br /> <br /> / ~lt ~V AND STATE SIGNATURE OF ~NOIOATE~FF~E~OER <br /> Execut~ on At By <br /> DATE CffY AND STATE SIGNATURE OF ~NDIDATE~FF~E~DER <br /> Executed on At By <br /> DATE C~Y AND STAT~ SIGNATURE OF ~NDIDATE~FICEHOLDER <br /> <br /> <br />