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COVER PAGE <br />Recipient Committee Type or print in ink. Date Stamp <br />Campaign Statement <br />Cover Page <br />(Government Code Sections 84200-84216.5) <br /> Statement covers period Date of election if applicable: <br /> from Y~¢~//*~) & (Month, Day. Year) OCT 2 3 Z0O3 of <br /> Fo~ Official Use Only <br /> <br />SEE INSTRUCTIONS ON REVERSE through /0--/8~' '.,~ //~'/--~' O~,~ CiTY OFC!TY ~ ~_~:;,'::~OD CtTYcLERK <br /> <br />1. Type of Recipient Committee: All Commltlees- Complete Pads 1, 2, 3, and 4. 2. Type of Statement: <br /> [~ceholder. Candidate Controlled Committee [] Ballot Measure Commiltee ~"~reelection Statement [~] Quarteriy Statement <br /> O State Candidate Election Committee O Primarily Formed [] Semi-annual Statement [] Special Odd-Year Report <br /> O Recall O Controlled [] Termination Statement [] Supplemental Preelection <br /> (A~oC, omp~teP~r~,5) O Sponsored [] Amendment (Explain below) Statement - Attach Form 495 <br /> (Also Complete P~I 6) <br /> [] G Purpose Committee <br /> 0 Sponsored [] Primarily Formed Candidate/ <br /> O Small Contributor Committee Officeholder Committee <br /> O Po~ilical Party/Central Committee (,~o c~,np~e ~ :~ <br /> <br />:3. Committee Information I I.D. NUMBER ., ~ ; <br /> COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) NAME OF TREASURER <br /> <br /> MAILING ADDRESS <br /> STREET ADDRESS (NO P.O. SOX) CITY STATE ZIP CODE AREA CODE/PHONE <br /> <br /> CITY STA~ ZiP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURE~r, IF ANY <br /> <br /> MAILING ADDRESS (IF DIFFERENT) NO. AN E7 OR P.O. SOX MAILING ADDRESS <br /> <br /> CITY STATE ZIP CODE AREA CODE/PHONE CITY ZIP CODE AREA CODE/PHONE <br /> <br /> OPTIONAL: FAX I E-MAIL ADDRESS OPTIONAL: FAX I E-MAIL ADDRESS <br /> <br />4. Verification <br /> I have used all reasonable diligence in preparing and reviewing this statement and Io the best of my knowledge the information contained herein and in the attached schedules is true and complete. I <br /> certify under penally of perjury under the laws of Ihe State of California that the foregoing is true and correct. <br /> <br /> Executed on By <br /> <br /> Exec~Jted on Date By SignaturedCo~O~*.:eholde~.Candidate. SaaMeasumPmpene~ FPPC Fon-n 460 (June/D1) <br /> FPPC Toll-Free Halpllna: 866/ASK-FPPC <br /> State of California <br /> <br /> <br />