La Berge 01-13-1998 Termination 416

Browse Search

OFFICEHOLDER AND CANDIDATE Officeholder and Candidate STATEMENT OF TERMINATION Statement of Termination This form must be completed by officeholders and WHERE TO FILE: ~ ~ ~ ~ ~ candidates that are eligible to terminate pursuant Officeholders and candidates must file to Government Code Section 84214. Form 416 with the fill ng officer with whom they filed their original campaign Type or print in ink. statements (Form 470 or 490). I Officeholder or Candidate Termination II Office Sought or Held NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD FOR WHICH YOU ARE FILING THIS STATEMENT RESIDENTIAL C~BUSINESS ADD'RESS (~ NO. AND STREET JURISDICTION (IF APPLICABLE) CITY v STATE ZIPCODE III Effective Date of T n AREA CODE/DAYTIME PH R DATE FILING OBLIGATIONS WERE COMPLETED IV Verification For the office listed in Part II of this form, I verify that: ~ A. do not hold or am no longer a candidate for the office; B. have ceased to receive contributions and make expenditures; C. do not anticipate receiving contributions or making expenditures in the future; D. have eliminated or I declare that I have no intention or ability to discharge all debts, loans received, and other obligations; E. have no surplus campaign funds; and F. have filed all campaign statements required by the Political Reform Act disclosing all reportable transactions. I have used all reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the information contained herein is true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. w ~DATE CIT SIGNATURE OF OFFICI~LDER OR CANDIDATE 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. State of California Fair Political Practices Commission