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Recipient Committee RECIPIENT COMMITTE~ <br /> WHERE TO FILE: _._____ STATEMENT OF TERMINAT;?,N <br /> Statement of Term in atio n F,e original and one copy of this form with: r~ <br /> Secretary of State I,., r~ (~ ~ 0 ~ r~ r <br /> This form must be completed by recipient committees Political Reform Division II U J <br /> that are eligible to terminate pursuant to Government ' <br /> <br /> Sacramento, CA 95812-1467 ~ For Official Use Only <br /> <br /> ~ype or print in ink. And, If applicable, file one copy of this form w~- <br /> The city or county officer, if any, who receives ~e <br /> committee's campaign disclosure statements. ~ <br /> I Recipient Committee Information II Treasurer Information <br /> <br /> ADDRESS OF COMMITTEE NO. AND STREET <br /> <br /> CITY <br /> STATE ZIP CODE <br /> <br /> ~REA (ODE~AYTIME <br /> (¢/~) ~ - ~%~ III Effective Date of Termination <br /> DATE FILING O~LIGATIONS WERE COMPLETED <br /> IV Verification ~ ~' <br /> <br /> A. This committee has ceased to receive contributions and make expenditures; <br /> <br /> B. This committee does not anticipate receiving contributions or making expenditures in the future; <br /> C. This committee has eliminated or declares that it has no intention or ability to discharge all debts, loans received, and other obligations; <br /> <br /> D. This committee has no surplus funds; and ' <br /> E. This committee has filed all campaign statements required by the Political Reform Act disclosing all repo~able 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 ce~ify under penalty of perjury under the laws of the State of Calif~t the foregoing is true and correct. <br /> <br /> Executed on 7 ~ At ~ ; By / <br /> 51GNA~UR( OF CONIRO[[ING O[[IC[HOtD[R, CANOIDA~[, OR ~AI[ M[A~UR[ PROPONEN~ <br /> Executed on At <br /> DATE CITY AND SEATE <br /> <br /> SIGNATURE OF CONIROLLING OFFICEHOLDER. CANDIDATE. OR SLATE MEASURE PROPONE <br />FOR INFORMA?ION REQUIRED TO BE PROVIDED TO YOU PURSUANT TO THE INFORMATION P~CTICE5 ACT OF 1977. SEE INFORMATION MANUAL ON CAMPAIGN DISCLOSURE PROVISIONS OF THE POLITICAL REFORM AC1 <br /> <br /> State of California relr Political Practices Commls¢on <br /> (Call The Fair Political Practice~ Commkdnn'~ T~rhnlrnl A~i¢lnnf~ ~ivi~Jnn nf ~1~1 ~?-q~ f~r ~;,~ ..... ~ <br /> <br /> <br />