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Recipient Committee <br />Campaign Statement <br />Cover Page <br />(Government Code Sections 84200-84216.5) <br />SEE INSTRUCTIONS ON REVERSE <br />Type or print in ink. <br />Statement covers period Date of election if app !cable: <br />from July 1, 2016 (Month, Day, Yea. <br />through December 31, 2016 <br />1. Type of Recipient Committee: All Committees — Complete Parts 1, 2, 3, and 4. <br />® Officeholder, Candidate Controlled Committee ❑ Ballot Measure Committee <br />0 State Candidate Election Committee 0 Primarily Formed <br />0 Recall 0 Controlled <br />(Also Complete Part 5) 0 Sponsored <br />(Also Complete Part 6) <br />❑ General Purpose Committee <br />0 Sponsored <br />0 Small Contributor Committee <br />0 Political Party/Central Committee <br />❑ Primarily Formed Candidate/ <br />Officeholder Committee <br />(Also Complete Part 7) <br />3. Committee Information I.D. NUMBER <br />1374422 <br />COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) <br />Committee to Elect Janet Borgens for Redwood City Council 2015 <br />STREET ADDRESS (NO P.O. BOX) <br /> <br />CITY STATE ZIP CODE AREA CODE/PHONE <br />Redwood City Ca 94063 ( <br />MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX <br />CITY STATE ZIP CODE AREA CODE/PHONE <br />OPTIONAL: FAX / E-MAIL ADDRESS <br />COVERPAGE <br />Date Stamp CALIFORNIA <br />"00 1/02 <br />RECEIVED •' <br />Pag 1 of 5 <br />JAN 3 Q 2017 For Official Use Only <br />City of Redwood City <br />2. Type of Statefpx+' „ City Clerk <br />❑ Preelection Statement <br />❑ Quarterly Statement <br />® Semi-annual Statement <br />❑ Special Odd -Year Report <br />❑ Termination Statement <br />❑ Supplemental Preelection <br />❑ Amendment (Explain below) <br />Statement - Attach Form 495 <br />Treasurer(s) <br />NAME OF TREASURER <br />Hollis Matheny <br />MAILING ADDRESS <br /> <br />CITY <br />STATE ZIP CODE AREA CODE/PHONE <br />Fremont <br />Ca 94536 ( <br />NAME OF ASSISTANT TREASURER, IF ANY <br />MAILING ADDRESS <br />CITY STATE ZIP CODE AREA CODE/PHONE <br />OPTIONAL: FAX / E-MAIL ADDRESS <br />4. Verification <br />1 have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the i rmation 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 true <br />correct. <br />Executed an <br />Dat � % By <br />/ Signat o XreasurerorAssistantTreasurer <br />�� % <br />Executed ory / B <br />' Date y , nature oft trolling Officeholder, Candidate. State Measure Proponent or Responsible Officer of Sponsor <br />Executed on By <br />Date Signature of Controlling Officeholder, Candidate, State Measure Proponent <br />Executed on 460 BY <br />Date Signature ofControlling Officeholder, Candidate, State Measure Proponent FPPC Form (June/01) <br />FFFC IVII-Frac Hv;pi 1v* OVVIA3K-FPPC <br />State of California <br />