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Recipient Committee <br />Campaign Statement — Short Farm <br />Type or print In ink. Statement covers period <br />Amounts may be rounded !! <br />to whole dollars. from <br />SEE INSTRUCTIONS ON REVERSE through b - s o- t Ct <br />NAME OF COMMITTEE <br />141 <br />5. Payments Made (nnwe space is needed, use addtdonal copies of page for conNnrradon sheets.) <br />NAME OF CANDIDATE AND OFFICE OR <br />DATE* NAME AND ADDRESS OF PAYEE DESCRIPTION OF PAYMENT NAME OF BALLOT MEASURE AND <br />(IFOOMMmEE, ALSOEWER LO. NUMBER) BALLOT NUMBER OR LETTER <br />AND JURISDICTION <br />N/� <br />* Required only for payments which are contributions or independent expenditures. <br />0 Support Q Oppose <br />0 Contribution 0 Ind. Exp. <br />(� Support Oppose <br />0 Contftuton 0 Ind. Exp. <br />0 Supper 0 Oppose <br />0 Contri Won Ind. Exp. <br />SUBTOTAL $ <br />AMOUNT <br />THIS PERIOD <br />SHORT FORM, <br />CALIFORNIA <br />Page 3 of <br />I.D. NUMBER <br />1-3Y'7tt5 <br />CUMULATIVE <br />AMOUNTS TO DATE* <br />Calendar Year <br />S. <br />Other <br />a <br />Calendar Year <br />5 <br />Other <br />Calendar Year <br />S <br />Other <br />FPPC Form 450 (January/05) <br />FPPC Tall -Free Helpline: 86MASK-FPPC (866/2764772) <br />