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SHORT FORM <br />Recipient Committee Type or Print tn Ink. Stat®m®nl coVell p®rlod Dalo $1amp <br />Campaign Statement--Short Form <br /> <br />For use by ~eclpient ~itlees w~ch have nol ~eiv~ a con~ibudon or off,er r~eipt which <br />mus~ ~ ilemiz~, have nol ~cceived o~ m~e lo~s, ~ have no ou~l~d~g accrued ex~mes or P~g~ <br />e~ozceable p~omises r~eiv~. <br /> <br />Oheok one gl Ihe Iollowlng bo~e~ Io Indloale Ih~ lype gl slalement being filed: {Monlh~ Day~ Year} <br /> <br /> C~TY <br /> ~ Semi-a~ual Slat0m0nt ~ 8pec~l Odd-yea~ Campaign <br /> ~ ~pple~ntal P~o-olecti~ Statom~l (Alta~ a ~mplolod Fo~m 495 Io Ibis slalem~t.) <br /> ~ Torm~at~n ~tal~enl (Allach a c~ploted ~rm 415 to this slat~enL) <br /> <br />I Oommiltee InlormaUon <br /> <br /> c~ ~ ' ~ z~c~ <br /> <br /> ~is committee h~ not ~eceived any con~butions, cumulative conaibufions or miscell~eous r~eip~ ~rom a single murce Iomling $ I~ or more which must ~ itemize, ~d <br /> · is committ~ h~ not ma~ or ~eived Irons, ~d has no accm~ ex~n~s or oum~nding enforc~ble promi~ <br /> I have u~ all re~nablo diligen~ in prep~ng ~i~ s~temem. I have ~eview~ ~e statement and ~ ~e ~t o[ my knowledge ~e infomafioa con~n~ he.in is ~e and <br /> cmnple~. I ceffify under ~lty o[ ~rju~ under ~e laws of ~e State of C~ifomia that the f~egoin~ and c~t. <br /> <br /> An officeholder, can~da[o, or s~ m~sure pro~nenl who c~ols a commiu~ must also verify ~e c~i~ s~lement. <br /> <br /> I have u~d all re~onable diligence ~d m the ~st of my knowledge ~e ~e~urer h~ us~ all r~sonable diligence in prep~n~ this s~temen[. I have reviewed lhe s~ment <br /> ~d Io [he ~st of my knowledge ~c info~adon con~n~ heroin is ~e and complele. ] ce~fy under ~nally of ~du~ under <br /> <br /> Execuled on Al By <br /> Execut~ on ~ By <br /> Exerted on N By <br /> <br /> <br />