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Officeholder and Candidate Type o, print inlnk. SHORT FORM <br /> <br /> Campaign Statement -- Short Form D,teStamp <br /> (GovernmentCodeSect,onS~,206) [~ [~ r~ 0 ~ ~ ForOffi¢ialU,eOnly <br /> For use by officeholders and candidates who do not have a contr~lled committee and who do not anticipah <br /> receiving $1,000 or more in contributions and do not anticipate spending $1,000 or more during the <br /> calendar year. Officeholders whose salar~ is less than $100 per month and judges who have a controlled ~ ! 3 ~ <br /> committee may use this form under certain circumstances See the Information Manual on Campaiqn <br /> Disclosure Provisions of the Political Reform Act for Elected Officeh01ders, Candidates, a~d Their '~ <br /> ~Omm~ttees ~~ 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 OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD <br /> <br /> ~SIDENTIAL OOUSINESS ADDRESS [~ AND ~TREET) JURISDICTION (LOCATION~ ~ I DISTR,~ NUMBER <br /> / <br /> <br /> AR~A CODE/DAY~IM~ PHONE NUMBE~ <br /> <br /> IV Committee Information <br />~ List all committees of which you have knowledge that are primarily formed to receive contributions or to make expenditures on behalf of your candidacy. <br />~ COMMIIT,E[ NAM[ AN.p I p NUMBER (~@MMITTEE ADDRESS i I~AME QI: TREASURER <br /> <br /> V Verification <br /> I declare under penalty of perjury that to the best of m~. knowledge, I anticipate that I will receive less than $1,000 and that I will spend less titan $1,000 during <br /> the calendar year and that I have used all reasonable ddigence 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. <br /> Executedon / /'To/~r~7 At ~,,~~ ~ C ~_ ~~- <br /> <br /> FOR iNFORMAl I()N fl( QIHfl[ fa IO 8E PROVIDED TO YOU PtJRSUANI TO 111[ INFORMATION P~CTICES ACT Of 1917 S[ [INtORMATION MANUAl ON CAMPAIGN DISCtOSUR[ PROVISIONS Of IH[ POLITI~L REFORM ACT <br /> State of Califmnia Fair Political Practi(es Commission <br /> <br /> <br />