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Recipient Committee COVER PAGE <br />Campaign Statement Type or print in ink. Date Stamp <br /> <br />Cover Page <br />(Government Code Sections 84200-84216.5) <br /> Statemeot c,ov~rs,~2p~eriod Date of election if applicabl~ <br /> <br /> from ..... /_/_¢~ '__- (Month, Day, Year) JUL <br /> For Official Use Only <br /> <br />SEE INS IRUCTIONS ON REVERSE through C~TY CLERK <br /> <br />1. Type of Recipient Committee: All Committees - Complete Parts ~, 2, 3, and 4. 2. Type of Statement: <br />  Officeholder, Candidate Controlled Committee ~ Ballot Measure Commi~ee ~ Preelection Statement <br /> Qua~edy <br /> Statement <br />  State Candidate Election Committee O Pdmadly Formed .~ Semi-annual Statement <br /> Special <br /> Odd-Year <br /> Repo~ <br /> Recall O Controlled ~ Te~ination Statement <br /> (AI~ Comple(e Pa~f 5) O Sponsored ~ Supplemental Preelection <br /> (A~ Co~. P.~ ~) ~ Amendment (Explain below) Statement - A~ach Form 495 <br />  General Pu~ose Committee <br /> O Sponsored ~ Primarily Foxed Candidate/ <br /> ~ Small Contributor Committee O~ceholder Committee <br /> O Politi~t Pady/Central Committee (AI~ ~plete PaR ~ <br /> <br />3. Committee Information ILO. NUMBER /~.~~ Treasurer(s) <br /> COMMIT] EE NAME (OR CANDIDATE'S NAME IF NO COMMI~EE) NAME OF T~SURER <br /> <br /> NAME OF ASSISTANT TREASURER, IF <br /> MAI~I;G ADDRESS (IF DIFFERENT) NO. AND STREET OR RO. SOX MAILING ADDRESS <br /> <br /> CITY STATE ZIP CODE AREA CODE/PHONE CI~ STATE ZIP CODE AREA CODE/PHONE <br /> OPTIONAL: FAX / E-MAIL ADDRESS OPTIONAL: FAX / E-MAIL ADDRESS <br /> <br />4~ verification <br /> <br /> I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledg~he information contained herein and in the a~ached schedules is ~rue and complete. <br /> certify under penalty of perju~.under the Jaws of the State of California that the foregoing is true and corre~//. <br /> <br /> Executed on By <br /> <br /> v ~te ~ Signature of ConSol ing ~fl~hot~r~n~, ~tate Measure Pro.riehl or Responsible O~r of S~n~r <br /> <br /> Executed on ~ By ~ . <br /> Date Signature of Con,oiling O~ceholder, Candidate, S~te Measure Prurient <br /> <br /> Executed on By <br /> Date Signature of ControlLing O~ceholder, Candidate, State Measure Pr~onent FPPC Form 460 (Ju ~e/01) <br /> FPPC Toll-Free Helpline: 866/ASK-FPPC <br /> State of Californi~ <br /> <br /> <br />