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LONG FORM <br /> Officeholder, Candidate, Type or Print in Ink. Statement covers period Dal0 $1amp <br /> <br /> and Controlled Committee <br /> Campaign Statement -- Long Form f,o.~3fl~_~ ~ - lqq 1 <br /> SEE INSTRUCTIONS ON REVERSE le / ol,~ / <br /> Check one of the following boxes to indicate the type of statement being filed: Date of Election A For Official Use Only <br /> [] Pre-eleclio~ Stalemen, If.pp,ic.bl.: JAN t 5 1992 <br /> [] Supplemental Pm-electicx~ Statement (Altach a completed Form 495 Io this slatemenl.) (Month, Day, Year) <br /> l~Semi-annual Statemenl iX[/A <br /> [] Tarminalion Statement (Attach a compleled Form 415 Io Ibis statement.) - · <br /> <br /> Officeholder, Candidate, II Other Committees Not Included in this Statement: List any other <br /> and Controlled Committee committees not included in this consolidated statement that are controlled by you and any <br /> Included in this Statement committees of which you have knowledge that are primarily formed to receive cotUributions or <br /> nn~ OF OFE~.Y~.D~a O.C. nO~TE: to make expenditures on behalf of your candidacy. <br /> <br /> ELD: (INCLUOE LOCATION AND ~ISTRI~! NUIdI~R N: APPLICABLE) <br /> <br /> fiEgi~-nfl~ o~ ~.:is ~: ~NO A~OSTFL ~ NAME O~ IREASUREA: CO~TROtLED COMMITi£E? <br /> CITY STATE ZiP CO0~ eI A~EA COOFJOAYTII~E PHONE COMMITTEE ADORE,SS: (NO AND STREET) <br /> COk~II~I'EE NAME: I I D. NUMI~R CITY STATE ZIP ~ AREA COOE~YIIME PHO~IE <br /> <br /> COMMITI*EE ADOAESS: (NO. ANO STREEI') <br /> <br /> ' ' ' ' STATE ' ' AREA COOE/OAYTIME 18HONE NAME CXc TRF..ASL~ER: CO~TROLLEO coMMfrr£E? <br /> <br /> NAME OF TAEASUflER: COklMITTEE ADORE.SS: (NO. AND STREET) <br /> PERMA,I~EN'I'-AD(~RESS OF TREASURER- (NO. ANDaSTREET) CITY STATE ZIP CO(~ AR EA C OI~--.jOAYI lid E PH(~IE <br /> <br /> - · STATE ZIP CO~ <br /> CllrY <br /> /~.,~ O ~-~t~"~ ~ q~ob ~ nalin/°rmali°n°naPpr°prialelylabeledc°ntinuali°nShee`$' <br /> <br />i Ill Verification Officeholder or Candidate: <br />, Treasurer: I have used all reasonable diligence and m thc best of m~knowicdgc the Izeasurer has <br />~ I have used all reasonable diligence in preparing this smtemcm and m the best of my used all reasonable diligence in preparing this statement. I have reviewed thc slate- <br /> knowledge thc information contained herein and in the auached schedules is true and menl and to thc best of my knowledge the information contained herein and in the <br /> complete, i certify under penally of perjury under thc laws of Ibe State of California attached schedules is Irue and complete. I certify under penalty of perjury under the <br /> that the foregoing is tree and correct, laws of thc State of California that the foregoing is tree and correct. <br /> Execuledon~L~(~A, ~/~la~O~)"~ Cl~ ~,,~"1~ tot' Execuledon~, (~l:~t~l~)e~ <br /> <br /> FOR tI~MATI~I FIF~LJIRED T~ BE PRO¥i~E~ TO YOU PURSUIT T© TIdE IP4F(:~ATI(::~ PRACTICES ^CT OF 197Z. SFE I~FOFIM^TION M~NU~ ~ C~VIP~IG~ C)ISCLOSUFIE PROVISK:~IS ~F TIlE POLIDC^L REFOFIM <br /> Stato of Californl& ~air Political P~aclico~ Commi~ion. <br /> <br /> <br />