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Officeholder, Candidate, Type Or print in ink. COVER PAGE- LONG FORM <br />and Controlled Committee Statement covers period Date Stamp <br /> <br />Campaign Statement -- Long Form ,,om <br />(Government Code Sectiom 84200-84216.5) <br />SEE INSTRUCTIONS ON REVERSE through . <br /> <br />Cbe~ one of the followM~ boxes to indi~te the type of stltement bein~ filed: Data of ole(tion if Ippli~ble: <br /> Pr,,I,~n Stat, m,~ (MO~,y.V,,.) I~[C I § ForO,~i.~ U, On~y <br /> Supplemental PrHl~'tion Statement (Att~h a completed Form 495 to this statement.) <br /> Special Odd-Year C&mpeign Report <br /> <br /> Termination Statement (Att~h I completed Form dlt $ to this statament.) <br /> tatement: <br /> In4 lis Statement <br /> NAME OF OFFICEHOLDER OR CA~ . . . committees of which you have knowledge that are primarily formed to receive contributions <br /> <br /> -- ' ~ L' G O~,.~:~ V" [ ~"~ \ Or to make expen(~turesonbeha/fofyourcendk:lac~'. <br /> COMMIT~E lo, ME I.D. MUMBER <br /> OJrFICE ~ Ol~ HELD ~IC~UDE LOCATION ~M) DISTRICT ~ I <br /> <br /> ~sm~m~L o~ mmMss ~ooMs~ Iw~..~m) ST~ET) ~ NAME m TMASU~n CONTWOLLEO C0MMrnEEt <br /> <br /> . .A. .c...C--'''-- <br /> ¢OMMITTE! ADOREii I <br /> GTY CONTROLLED COMMITTEII <br /> <br /> NAME OF TREASURER \ ' - CO~am~E ~SS MO. A,O STart) <br /> I~RMANEMT . AND STREET) CITY STATE ~ CODf AREA C(~yTWIr PHONE <br /> <br /> OTY STATE ~1' CODE AIIEA _ _t~ _4)AYTIME IqaO~E <br /> AKach ad,Y/oriel/nforn~don on appropdate/y/abe/ed continuation shaet~ <br /> <br /> I <br />III Verification <br /> I hove used all reesonabie diligence'in preparing this statement. I have reviewed the stltemont and to the best of my knowledge the informatiofl contained herein <br /> true and compMtt ! certify under penalty of perjury_undo_ r the laws.of the. State of C~liforni& thlt the foregoing is true Ind correct. /~ j/~. <br /> Executed ou P'tq'q5 ' At ~ <br /> DATE CITY AND STATE ~ SiGNATW~ or TI~ASUMR <br /> <br /> An officeholder or cendldlto who controls · committee must lbo verify the campaign stJtement. I have used ei~esonlblM difigenc~e a n(l~to the best of my knowledge the trelsu~er has used all <br /> reesonabia diligenca in praparin9 this statement. I hive reviewed tha stltemant Ind to the best o! my k nowiec~? ~he info~ltion c/~tai,l(/i%cl herein Ind in the a~ched schedules ~s true ..nd <br /> complete. I certify unde~ pena.hy of..~qury under ~ llws of the State <br /> <br /> DATE ' ' OT¥ ANI) STAll (~ * / , ~IG#ATORE Of CA#~DATE/O~tI(IHOLDER <br /> Executed on, At By <br /> DATE cny AND STATE SIGNATURE Of CANDIDATE/OfFICEHOLDER <br /> <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE Of CANDIDATE/OfrlCEHOLD! R <br /> <br /> FDA INFOP, MATION REQUMI. ID TO BE I~K)VIO~D TO YOU PUJ~SUAN1 TO THE INFORMATION PI~ACTICES AC1 Of Ig77. SEE INFORMATION MANUAL ON CAMPAIGN DISCLOSL)RE PR~VISI~$ Of THE POlITICAlr REFOfUd A(~, <br /> <br /> <br />