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TERMINATION <br />Statement of Termination TVp' or Prhll In Ink. Dale$1amp <br />This form must be complelcd by officeholders, candidales, and recipient commillccs RECFJVED <br />Ihat wish Io Icnninatc pursuant to Government Code Section 84214. ~--~// AND FILED A <br /> // <br /> -, tine Ot~ce ot the Secretary 0! Stale <br /> <br />whom they file Ibc originals of Iheir campaign sla~cmcnls.' <br />Commit~c~'.s file an o~iginal of Ibis form with Ibc Secrc~'y of $1a~c and, ii' applicable, <br />a copy wi~h Ibc local filing officer. <br />I Officeholder or Candidate Termination I Reoipien! Committee Termination <br /> <br /> a4~- A SS: J¢ C~.CO~. - ~ ~ <br /> <br />II Infer naUon on Office Sought or Held II Treasurer Information <br /> <br /> LCX~AllC~ (F A~PLI~ASLE) / D~Sl RICT NUUBER pF AP~L~ P~dE ~NT ~ ~F TflF-ASU~K / <br /> .L <br /> <br /> ARE~ COO¢~OAY~IM~ PHONE NUMB~ ~/ ! E~EClIVE OA~E (~ ~ERMII~IOI~ <br /> <br />I~ Ve~flcation I~ Verification <br />I h~ve u~d all rc~na~c di~g~cc ~ prcp~8 ~s stmcm~t. ! have cc,ed ~ r~eive ! have u~d ,!1 re~nablc ~iig~co ~ prcp~ ~s slmcm~t. ~is co~it~ <br />~6o~ ~d m~ ex~i~; do not ~ticipt~ r~eiv~ con~tio~ or r~ of rcceive ~nuibuQo~ ~ m~e execrates; ~s ~t ~t~ipa~ r~eiv~g ~i~6o~ or <br />ou~S io~ m~ M o~crs or ~y o~er rccci~s, or m~ng cx~itmcs h ~ ~mre; repa~cnu of outst~d~g Io~s ma~ to o~ers or ny o~er r~i~, or m~in~ cx~dit~cs <br />have cli~a~ or ~iue ~ I bye ~ ~nQon or n~li~ to dlsch~gc all ~, ~ ~e ~ture; hu el~at~ ~ ~lMcs ~m it hu <br />r~v~, ~d o~cr ~ligm~M; have no s~lus ~s; ~d ~ave fi~d ~1 c~paign su~ments ~ r~ived, ~d o~ oblisn~om; hu no s~lus ~n~; ~ hu fi~ nil c~paign s~- <br />rqu~ by ~ Poli~cai Rcfo~ Act d~closinf MI rc~ubtc u~act~ns. ~nu requ~ by ~ Poli6cd Rcfo~ Act d~c~sins <br />! ~ ~r ~d~ of ~rj~ ~cr ~c laws of ~e S~ of CMifomia ~nt ~c fmego~ is I c~6~ u~r ~Mty of ~rj~ u~cr ~e laws of ~c S~ ofC~ifomia ~at ~e f~ego~g is <br /> <br /> By <br /> <br /> Exe~l~ ~ <br /> <br /> NOTE: A~ltm~ fill~ o~iga~n~ will be incited il ~ ~ce~lde~, ~n~ate, m ~ee Execul~ ~ <br /> b~s r~g ~ ~e~g ~s = receives the fmgiveness ~ a ban m repaym~ts ~ ~" <br /> ~s ~ lo o~ms = ~y o~er receipts. By <br /> <br /> F~ I~R~T~ RE~I~D lO ~ PROVIDED IO YOU ~JR~J~T TO 1tE I~OR~TI~ P~CT~ES ACT ~ t977. SEE ~OR~[~~ CAMP~ DI~L~ <br /> <br /> Slate ol Calilornla Fair Pdili~ll Pracllce~ Co~ssion. <br /> <br /> <br />