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I <br />Officeholder, Candidate, Type o, print in ink. COVER PAGE- LONG FORM <br />and Controlled Committee Statement covers period Date Stamp <br />Campaign Statement -- Long Form ~ ~ ~] <br />(Government Code Sections 64200-84216.5) <br /> <br />SEE INSTRUCTIONS ON REVERSE <br />Check one of the following boxes to indkate the type of statement being filed: <br /> H Pre-election Statement <br /> Supplemental Pre-election Statement (Attach a completed Form 495 to this statement.) <br /> [] Special Odd-Year Campaign Report <br /> [] Semi-annual Statement <br /> G~i Termination Statement (Attach a c°mpleted F°rm alS't° this statement') <br />I, Officeholder. Candidate° and Controlled Comm,ttee menS: U. anyot~e. <br /> Included in this Statement corem/trees not In(luded in t/ds conso//dated statement that are controlled by you and any <br /> corem/trees of whkh you have knowledge that are primarily formed to race/ye contdbut/om <br /> NAME Of OFFICEHOLDER OR CANDIDATE or to make exipend/tures on beha/f of your candidacy. <br /> <br /> OffKE SOUGH10~ fl~LO (INGU~ LOCAIlON &ND DISTNCT NUMIEfl I~ AI~tlCABLE) <br /> <br /> R~SIDEmlAI- OR BUSaNESS ADDRESS /- (NO, AND~STREET) ' I NAME Of TREASUI~K CONTROLLED (OA4MIiJttJ <br /> <br /> ' ' STATE ~ CODE AJ~A C~YTI~E Iq'lONE COIdM/TI'CE ADDRESS (NO. AND STI~ET) <br /> CITY <br /> <br /> ' ~ I LD. IdUA~BER CITY STATE ZiP CODE AREA CODEA)AYTIIdE <br /> COMMII'rEE <br /> NAME <br /> <br /> I COMMITTEE ADDICTS (NO. AND SII~ET) <br /> <br /> CONTROLLED COMMITTEE <br /> C/TY STATE ZIF' CODf AaEA COIXa)AYTIIdE IaflONl NAME OF TREASU~R <br /> <br /> NAME OF TREASURER I / coMim'r~! AOO~SS ~NO. AND STeEl) ..': <br /> V~VIA~. 4_~-~)L~ STAIE ZIPCODE AREACODE/DAYT.EPflOflE <br /> PERMA/~NT ADDi~SS O~ Ta~AsuI~R ~lO. AND SLEET) CITY <br /> <br /> OIY STATE ZI~ CO43~ AJI/dK CO(OJE)AYladE ~ , <br /> Altech additional informatton on appropriately labeled continuation shaet~. <br /> <br />III Verification <br /> I have used ell reasonable dilqlence in preparing this statement. I have reviewed the statement and tothe best of my knowledge the information contained herein and in the a~ached schedules is <br /> true and complete./I ceftin/under penalty of I~[J~ury uncler Ule I&~f~ of,1~tS~ite of c~Aifornia that the foregoin~ Ist~J/~4nd corr~__,~ // <br /> <br /> ' ' CiTY AND S1"KI~ ~GNATUR~ Of TREASURER <br /> <br /> An officeholder Of candidate who controls I committee must also verify the campaign statement. I have used all regs0n,able dil~ence and to,~ae ~est o~y.~k no~.. le,dge, th.e tr.ea, su~er, has us? all <br /> reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the iflTorm/l~en c/ofltlifle~he~fl/q)ct/~4~te attaCheD scneomes is true ina <br /> complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct ~/~ ~ ~//// / <br /> <br /> Ii)ATE CITY AND ~TATE ' ' SIGNATURE Of CANDIDATEK)~FICEHOLDE <br /> Executed on At By <br /> DATE C/TY AND STATE S~NATURE Of CANDIDATE/OfFICEHOLDER <br /> <br /> Executed on At By <br /> DArE CITY AND STATE SIGNAlURE Of CANDIDATE/OfFICEHOLDER <br /> <br /> FOR INfOfLMATION REQUIRED 10 BE PAOVIDEO TO YOU PURSUANT TO THE INFORMAIK)N PRACTICES AC10~ Ig77, SEE INFORIdATION IVlANVAL CHql CAMPAIGN OlSCLOSURJ[ PROVISIONS Of IHE POLmCAL REFORM <br /> <br /> <br />