Laserfiche WebLink
SHORT FORM <br />Officeholder and Candidate Type or print in ink. DateSlarnp <br />Campaign Statement--Short Form ¢/~;j/~;:y ~cAUF°RN~}'~470~: <br />(Government Code Section 84206) ~~~1,~ <br /> For Official Use Only <br /> <br />For use by officeholders and candidates who do not have a controlled committee and who do not anticipate <br />receiving $1,000 or more in contributions and do not anticipate spending $1,000 or more during the calendar <br />year. Officeholders whose salary is less than $100 per month and judges who have a controlled committee <br />may use this form under certain circumstances. See the Information Manual on Campaign Disclosure <br />Provisions of the Political Reform Act for Elected Officeholders, Candidates, and Their Controlled Committees <br />for further information. <br /> <br />I Statement Covers Calendar Year 19 <br /> <br />II Officeholder or Candidate Information III Information on Office Sought or Held <br /> NAME OF OFFICEHOLD/~R OR CAND~IDATE OFFICE SOUGHT OR HELD <br /> <br /> RESIDENTIAL OR BUSINESS ADDR[::SS (NO. AND STREET) JURISDICTION (L~CATION) DISTRICT NUMBER <br /> CITY STATE ZIP CODE DATE OF ELECTION (MONTH, DAY, YEAR) (IF APPLICABI~) <br /> AREA CODE/DAYTIME PHONE NUMBER _ <br /> <br /> List all committees of which you have knowledge that are primarily formed to receive contributions or to make ex ~enditures on behalf of your candidacy. <br /> <br /> COMMITTEE NAME AND I.D. NUMBER COMMITTEE ADDRESS NAME OF TREASURER <br /> <br />V Verification <br /> I declare under penalty of perjury that to the best of my knowledge, I anticipate that I will receive less than $1,000 and that I will spend less than $1,000 during <br /> the calendar year and that I have used all reasonable diligence in preparing this statement. I certify under penalty of perjury under the laws of the State of <br /> California that the foregoing is true and correct. ~'-- "~ F"-- '~ <br /> DATE ' CITY AND STATE · '~ SIGNATURE OF OFFICEHO(.DER OR CANDIDATE <br /> <br /> FOR INFORMATION REQUIRED TO BE PROVIDED TO YOU PURSUANT TO THE INFORMATION PRACTICES ACT OF 1977, SEE INFORMATION MANUAL ON CAMPAIGN DISCLOSURE PROVISIONS OF THE POLITICAL REFORM ACT. <br /> State of California Fair Political Practices Commission <br /> <br /> <br />