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SHORT FORM <br />Officeholder and Candidate TV,--- ~.t ~ ~k ~ s~.~ <br />Campaign Statement -- Short Form <br />(~ove~'nmeniCod¢ Section 84206) A F= Officml Use Only <br />F~ ~ by ofP~choldcrs ~d c~dida~s w~ ~ nm ~vc a conu~ll~ commilt~ a~ who do nm ~dcipam r~civ~g ~: ~': ~' ~ ~ · <br />$1~ ~ ~rc in ~uibudms ~ ~ ~l andci~lc s~nding $1~ or mom du6ng ~ ~l~c c~cn~ y~. <br />OfF~l&rs w~ s~ is b~ ~ $1~ ~r mon~ ~d judges who have a conuoll~ commil~c may u~ ~is for~ <br />un&r c~n c~c~s. Sec ~c appmp~m inf~mion Manual on Camoaien Di~losurc ~ovisions of Ibc :-:. <br />~olil~ Rcf~ Act (Manu~ A) for fu~r inf~at~n. ~ <br /> CiTY OF <br /> <br />I Oflic~lder or GandidaI~ Inlonflon II InlormIion on Office Held or b~hI <br /> ~! ~ ~I I ~IAlh OF~ HI~ ~ ~NTI <br /> <br /> ~N~ ~ ~SS ~SS: (~. ~ S~ET) ~~ (L~T~N) ~STRET <br /> ~ ~IATE ~P C~ ~TE ~ [~CT~ (~1~, DAY, Y~ (F ~g~) <br /> <br />Ill biIIee Inlo~ofl <br /> List all co.trees of w~ch you ~ve bowledge that are pri~rily for~d W receive contributio~ or to ~e ~itures on be~ of ~ can~cy. <br /> <br /> C~EE ~ AND I.D. NU~R C~EE AD~E~ ~E ~ TR~SURER <br /> <br /> IV Ve~ation <br /> I declare under penally of perjury Ihnl Io Ibc best of my knowlcdgc, I nnticipalc Ihal I will receive less Ihan $ !000 ~ ~ ! will s~ ~ ~ $1~ ~ng ~ ~b~ ~ <br /> and ~ ! have used all Ib~ diligence in prcparifl$ Ihis slatcmcnL ! ceflify undez' penally of perjury under thc laws of thc Stale of Califomin thai Ibc foregoing is true and <br /> cerrccc ~ --Zz~ !~ ' ' <br /> <br /> FOR M~FORMATION REOU- IRED TO BE PROVIDED TO YOU PURSUANT TO THE INF(D~IMATIOJ4 PRACTICES ACT OF 1977, ,~E INF(3RMATIO~i MANUAL ON CAMPAIGN DISCI O.¢d_lRE PROVtS#3NS OF THE POLITICAL REFORM ACT <br /> <br /> St&t® ol Calilomla Fair ~olJtl~ad ~ractice~ Co~t~ds~lon. <br /> <br /> <br />