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Recipient Committee COVER PAGE <br /> Campaign Statement 7YPe or print in ink. Date stamp � �� � , <br /> Cover Page '" � ' <br /> (Government Code Sections 84200-84216.5) � Page�_ of <br /> Stateme t cove s period Date of election if applicable: <br /> � U-� (Month, Day,Year) ���7 For Official Use Only <br /> from <br /> SEE INSTRUCTIONS ON REVERSE through �Z � � � ' �' U � <br /> 1. Type of Recipient Committee: All Committees-Complste Parts 7,z,a,and 4. Z. Type of Statement: <br /> � Officeholder,Candidate Controlled Committee ❑ Primarily Formed Ballot Measure ,� Preelection Statement ❑ Quarterly Statement <br /> Q State Candidate Election Committee Committee ❑ Semi-annual Statement � Special Odd-Year Report <br /> Q Recall Q Controlled <br /> (AlsoCompletePart5) S onsored ❑ Termination Statement ❑ Supplemental Preelection <br /> � p (Also file a Form 410 Termination) Statement-Attach Form 495 <br /> (Also Complete Part 6) <br /> ❑ General Purpose Committee ❑ Amendment (Explain below) <br /> Q Sponsored � Primarily Formed Candidate/ <br /> Q Smail Contributor Committee Officeholder Committee <br /> Q Political Party/Central Committee (Alao Comp/etePaR 7) <br /> 3. Commlttee Informatlon I.D. NUMBER Treasurer(s) <br /> COMMITTEE NAME(OR CANDIDATE'S NAME IF NO COMMITTEE) NAME OF TREASURER <br /> /^ �� ,�, Ct 1? n r� �G� S 1�'�:% j� <br /> / ���� �"t�� � �I�G � �� � /c� '�h MAILING ADDRESS / <br /> l� ( �,� � <br /> <br /> ,� ,�e�'����� ��`fv , c� �i�-�G:� �� -���- <br /> CITY STATE ZIP CODE AREA CODEIPHONE NAME OF ASSISTANT TREASURER, IF ANY <br /> �� ���`�O-� C'i�`1',e , ��► °1�-�6 l �� ' <br /> MAILING ADDRESS (IF DIFFERE ) N ,AND STREET OR P.O. BOX MAILING ADDRESS <br /> CITY STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA CODEIPHONE <br /> OPTIONAL: FAX/E-MAIL ADDRESS OPTIONAL: FAX/E-MAIL ADDRESS <br /> 4. Verificatlon <br /> I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the information contained h rein and in the attached schedules is true and complete. I certity <br /> under penalty of perjury under the laws of the State of California that the foregoing is true and correct. <br /> Executed on��� ��� gy � -�' <br /> �� Sign ofTreaeurororA IstentTreeauror <br /> � � <br /> F�cecutad on � �� �� g <br /> Date y SipnatureofControllingOrtl der,Cendidete,SteteMeesureProponentorResponeible0}AcerofSponaor <br /> Executed on gy <br /> OaOe Sipneture of Controlling OTficeholder,Cendidete,State Meesure Proponent <br /> Executed on g <br /> Date y Signatureof Conholling OfAceholder,Candidale,State Measure Proponent FPPC Fortn 460(January/O6) <br /> FPPC Toll-Free HelpHne:866IA3K-FPPC(86W275�7T2) <br /> State of Calffornla <br />