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~'3fficer', older, Candidate, Typ,or printin ink. COVER PAGE- LONG FORM <br /> ' · Statement covers period Date St <br />· and Controlled Committee . ' 1- D,te_St~ ~ ~_~ <br />Campaign Statement Long Form ,rom~~~! /~/~ <br />(Government Code Sections 84200-84216.5) ~ / . ~1~ tl I~ ~ -- i! <br /> <br />Check one of the followlng boxes to iodkate the type of statement being flled Date of ehtction if a, Ical'ii':'~11 [?B ! ~'' I'll page / of <br /> <br /> [] Supplemental Pre-election Statement (Attach a completed Form 495 to this statement.) I ~.~D~~ ~' ' I <br /> I-1 Special Odd-Year Campaign Report I I r .... c~~---T- I <br /> [] Semi-annual Statement I ~-~ ...... I I <br /> E:] Termination Statement (Attach ? completed Form 41S to this statement.) ! ~ I <br />I, Officeholder. Candidate, and Controlled Committee II Other Committees ot Included in thJs Statement: u..n~otha. <br />Included Jn this Statement commutes not included in the como//dated statement that are controlled by you and any <br />NAM[ OF OFFICEHOLDER OR CANDIDATE comm/t~ees of which you have knowledge that are primarily formed to race/ye contributions <br /> <br /> COMMITTEE NAME <br /> I <br /> OffiCE SOUGHT Of~ H~LD 4N~ICLUOE LOC~TI(~J AN4) DISTRICT NUMBER Iir AI~LICABLE) I LD, NUMBER <br /> <br /> RJE S41~NTJAL Od BUSINESS ADDIq~ss (NO. AN~ STREET) ~ NAME Of TREASURER CONTROLLED COMMITTEE? <br /> C/TY STATE ZIP COOE COIdMrrEEE ADDRESS IND. AND STREET} <br /> <br /> COMMITTEE NAME c '~ I.D. NI~dRER - ~ STATE ZiP CODE AREA COOE~AYTI~AE <br /> <br /> I COIdMII~EE ADI~ESS (leO. AND STREET) <br /> STATt ZIP COOl AREA C4X)f.4)AYTB4E IIHONE NAME OI~ TREAsuaER CONTROLLED COMMITTEE t <br /> NAME OF TREASURER COMmrrEE ~me~ss IND. AND STREEt) . <br /> I~RMANEMT ADn~SS Of TREASURER ~H). AN~ STREET) CITY STAll ZiP COO! AREA CGOFJDAYTIME PHONE <br /> <br /> CITY STATE ZI~ COOl ~ COOf~AYTI~E PHONE <br /> <br /> Attach m~lleio~l lnfmmetion on appropct4tely labeled continuatlon sheets. <br /> <br />III Verification <br /> I have used ell reasonable diligence in prepering this statement. I have reviewed the statement and to the best of my knowledge the information contained herein and in the attached schedules is <br /> true and complete. I~erti~ under penalty of perj~j~y under the laws of th,e~Ltate of Califj~rnie that the foregoing is true a correct. . ~ , <br /> <br /> ~'/ ~T~ ' ' ¢IT¥ AND STATE f <br /> SIGNATURE O~ TREAf~URE# <br /> <br /> An offkehoMer m e~odkl~te wire controls · committee must also verify the cempelgn statement. I have used all reasonable d~en~e and ~the ~st of,~ kj~;~vledge the treasurer has used all <br /> reasonable diligence in preparing this statement. I hove reviewed the statement and to the best of my knowledge the in f.,o~T~9~r~;onta, jK'e~'h,e~in a)~,i~),~r~,~ttacbed schedules is true and <br /> complete. I certify 9ndqr penalty of perjury undAr the laws of the,,~tate of Calif.¢lrnia that the foregoing is true and cof~e~'// //// ~///. <br /> <br /> ' 1 'D~fE CITY AN6 STATE SIGNATURE Of CANDtDATE/Of~ICEHOLD~R <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE OF CANDIDATFJOfFICEHO(DER <br /> <br /> Executed on At By <br /> DATE CITY AND STATE SIGNAl URE Of CANDIDATE/OfFiCEHOLDER <br /> <br /> FOR INFC)PJMATIOfl REQUIRED TO BE PROVIDED TO YOU PURSUANT TO THE INIrOJUdATION PRACTICES ACT Of IS77. SEE INFORMATION MAN~JAL 9N CAMP.~,~GN DISCLOSURE PROVISIONS, C)f rile POLIIICAL REFORM <br /> <br /> <br />