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Officeholder, Cand id ate, Type or print in ink. COVER PAG E- LONG FORM <br /> and Controlled Committee stato.. ceve. pe,k D.to Stamp <br /> Campaign Statement -- Long Form ,,om <br /> (Government Code SectK)ns ~4200-84216.5) '~ -7 ] ................ ii~" <br /> <br /> Check one of the folowk~ boxes to indkJta the type of statement being filed: Data of election if ml~d~: of <br /> · Pre-election Statement (Moth. Day. Year) Fc~ Official Use Only <br /> Supplemental PrHleCbOn Statement (Attach, completad Form 495 to this statement.) J~ ~ 0 ~ <br /> Special Odd-Year Campaign Report A/ <br /> SemJ-~nnual Statement [¥ ) d. ~/-7 <br /> Termination Statement (Attach ~ completed Form 4! 5 to this statament.) CFI¥ OF <br /> <br /> conue/nees of wf~ch yo~ h4ve knowiK~ that m~e ~ ~ to rece/w <br /> <br /> CQMIJIT~ M I I.D. NUMIEll <br /> S41)~NTIAL Ofl 4NO. ANO STI~ST) ~ Q~ TMASUI~II CQNTaGL~D COMIdlTTEEt <br /> <br /> COMMITTEE NAME I LD. Nummm mY STATE ~COfX <br /> <br /> coMmm DAm I i.n. NUMBER <br /> COMMfflll AI)O~, ~NO. AND STRELrT) <br /> <br /> C~ STATE ~ CO(~ A~A CQO~4)AYTed~ ~ ~ ~ TIIF, A~UIIER CONTROLLED <br />· '~ NAME OF TREASU~R / ~mm ~emss m. Am STem <br /> ~mmAmm ~# ~ ~epJuma I~. ANI) ~m)il~) CITY STATE ZIP COOf AIIIA COf)fA)AYTIM( PHONE <br /> <br /> I have umcl IN real~Dnlble diligence la preparing this statoment. I have reviewed the statement and to the best of my knowlec~l the informetion contained herein mhd in the attached Khedules <br /> tmelndcempMtl. IciCtJfyundorpenaltyofperJu;yunderthelews .oftheS~tata.ofCiliforniathatthaforegolngistruelndcqf~/ect. A / ~ <br /> <br /> [ DATE / CITY AND STATE / ' SIGMATU~E Of TREASUIER <br /> <br /> An offkeholdor or cendldito who controls · commlttae must lbo verify the cJmpeign statement. I have used iii relson·ble diligence and to the best of my knowledge the tre·surer has used all <br /> rllsoneble dil~ence in preparing this statement. I have reviewed the statament and to the best of my knowledge the inf(xm·tion containad herein ·nd in the ·ttached schedules is true and <br /> complete.ExKutnd onl certify //"~O/q~under penalty of perjurYAt under~?~t~ L~O o~the llws of th(p S~_ iJ'~of~ ,Cnlifornia~ ~'/~that the foregoing is trueBy end correct...~__~..~{) ~.~ <br /> ~ DATE -- CITY ANO SLATY / S4GNATU~ Of CANOK)ATEK)~FICIHOLD(It <br /> <br /> i Executed on At By <br /> ~ DATE CITy ANO STATE S4GNAIUP. E Of CANDIOATE~OfFICEHOLIXR <br /> <br /> Executed on At By <br /> DATE CITY ANO STATE SIGNAIUPiE Of CANDIC)ATE/OfFICEH(XDER <br /> <br /> FO4q INFQ4~4ATION NQUI~O TO RE PROVIO(D TO YOU PU4GUANT TO THE INFOP. MATION PIMCTICES AC1 Of 1577, SEE INFOP, MATION MANUAL ON CAMPA~N DISCLOSURE P~O¥!SK)NS ~ !H~ PoLn~;A~ P~FgNd A~ <br /> <br /> <br />