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OFFICEHOLDER AND CANDIDATE <br />Officeholder and Candidate i STATEMENT OF TERMINATION <br /> Date <br /> Stamp <br />Statement of Termination ..... J <br />This form must be completed by officeholders and WHERE TO FILE: <br />candidates that are eligible to terminate pursuant Officeholders and candidates must file <br />to Government Code Section 84214. Form 416 with the filing officer with <br /> whom they filed their original campaign <br /> Type Or print in ink. statements (Form 470 or 490). <br /> <br />I Officeholder or Candidate Termination II Office Sought or Held <br /> NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD FOR WHICH YOU ARE FILING THIS STATEMENT <br /> <br /> NO. AND STREET JURISDICTION (IF APPLICABLE) D~STRICT NUMBER (IF APPLICABLE) <br /> <br /> C'~Y,~ STATE ZIP C.ODE <br /> )~/~C~:x~ ~_~ / '~ ~/~ ~ L/O /~ III Effective Date of Termination <br /> DATE FILIN~ OBLIGATIONS WERE COMPLETED <br /> <br />IV Verification ' <br /> For the office listed in Part II of this form, I verify that: <br />?1 do not hold or am no longer a candidate for the office; <br /> <br /> ::)1 have ceased to receive contributions and make expenditures; <br /> ~)1 do not anticipate receiving contributions or making expenditures in the future; <br />  :~1 have eliminated or I declare that I have no intention or ability to discharge all debts, loans received, and other obligations; <br /> ~ I have no surplus campaign funds; and <br /> (~)1 have campaign statements required by Act disclosing reportable <br /> filed <br /> all <br /> the <br /> Political <br /> Reform <br /> all <br /> transactions. <br /> <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 <br /> 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. <br /> <br /> FOR INfORMAIlON REQUIRED 10 BE PROVIDED TO YOU PURSUANT TO THE INFORMATION PRACTICES ACT OF 1977. SEE INFORMATION MAN~AL ON CAMPAIGN DISCLOSI~JI~ PROVISIONS Of THE POLITICAL REFOREM ACT. <br /> <br /> State of California Fair Political Practices Commission <br /> <br /> <br />