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Officeholder, Candidate, Type or print in ink. COVER PAGE- LdNG FORM <br />and Controlled Committee Statement covers period Date Stamp <br />Campaign Statement -- Long Form from /O/~ <br />SEEINSTRUCTIONSONREVERsE(G°vernmentC°deSecti°ns84200'84216'5) through /~.~/ <br /> Check one of the following boxes to indicate the type of statement being filed: Date of election if applicable: <br /> B Pre*electionStatement (Month, Day, Year) ~ i~ i ! BK t'~ For Official Use Only <br /> <br /> Supplemental Pre-election Statement (Attach a completed Form 495 to this statement.) <br /> I--] Special Odd-Year Cam paign Report / <br /> [] Termination Statement (Attach 6 completed Form 415 to this statement.) <br /> Off,ceholder, Candidate, and Controlled Committee II Other Committees I ioflncluded in this Statement: Lis~ any other <br /> Included in this Statement committees not included in this consolidated statement that are controlled by you and any <br /> NAME OF OFFICEHOLDER OR CANDIDATE corem/trees of which you have knowledge that are primarily formed to receive contributions <br /> o, to <br /> COMMITTEE NAME II.D. NUMBER <br /> C)t:FICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTINCT NUMIER IF APPLICABLE) <br /> I <br /> RESIDENTIAL STREET) NAME 04: TREASURER CONTROLLED COMMITTEE? <br /> <br /> CITY STAYE ZIP CODE AREA CODE/OAYTIME PHONE COMMn'TEE ADORESS (NO. AND STREET) <br /> <br /> COMMITTEE NAME ~__~7~C~1MI'D' NtealER (~C~ CITY STATE ZIP CODE AREA CODE/DA YTIME PHO%IE <br /> i COMMnTEE ADDRESS (NO. AND STREET) <br /> <br /> CITY STATE ZIP CODE AREA CODE~DAYTIME I~IONE NAME 04: TREASURER CONTROLLED COMMII~EE? <br /> NAME OF TREASURER COMMrr~E ADDRESS (NO. AND STREET) <br /> PERM&NENT ,ADDRESS 04: TREASURER (NO, AND STREET) CITY STATE ZIP CODE AREA CODE/DAYTIME PHONE <br /> <br /> CITY STATE ZIP CODE AREA CODE/DAYTIME PHONE <br /> ~~t.)~O,b e.,/']'~, 0/3(-. ~VO~,~ ~/ ~-~(.~ Aetachaclditionallnformationonappropriatelylabeledcontinuationsheets. ' <br />III Verification <br /> 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 hpjej,o.aod in the, attached schedules is <br /> true and complete. ,I certi~ under penalty of perjury under the laws of the State of California that the foregoing is tr~e and correct./~ <br /> <br /> CITY AND STATE <br /> D~E -- ' ' <br /> <br /> An officeholder o~ Mndldate who controls a committee must also verify the campaign statement. I have used all reasonable diligence and to the best of my knowledge the treasurer has used all <br /> reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the information contained herein and in the attacl]ed schedules is true and <br /> complete. I certify under penalty of perjury under the laws of the State of California that the foreqoing is true and correct./~ <br /> <br /> I DATE~ -- -- CITY AHD STATE ' .,~ ~ -- SIGNATURE OF <br /> CANDI~TE/OFFICEflOLDE R <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE OF CANDIDATE/OFFICEHOLDER <br /> <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE OF CANDIDATE/OFFICEHOLDER <br /> <br /> FOR INFORMATION REQUIRED TO BE PROVIDED TO YOU PURSUANT TO THE INFORMATION PRACTICES AC[ OF Ig77, SEE INFORMATION MANUAL ON CAMPAIGN DISCLOSURE PROVISIONS OF THE POLn'ICAL REFORM ACT. <br /> <br /> <br />