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Reci ientCommittee COVERPAGE <br /> p Type or print in ink. oace Stamp � <br /> Campaign Statement �'� ' � � 1 <br /> Cover Page <br /> (Government Code Sections 84200-84216.5) page of <br /> Statemen cover period Date of election if applicable: <br /> �%1 � Q (MOnth, Day, Y28�) For Official Use Only <br /> from � �"'"' <br /> SEE INSTRUCTIONS ON REVERSE through C O �� �� f � � v <br /> 1. Type of Recipient Committee: ,au comm�nees-compiete Pa��,s,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 ❑ Termination Statement <br /> (AlsoCompletePart5) � Sponsored Also file a Form 410 Termination � Supplemental Preelection <br /> (AlsoComp/etePart6) � � Statement-Attach Form 495 <br /> ❑ General Purpose Committee ❑ Amendment(Explain below) <br /> Q Sponsored � Primarily Formed Candidate/ <br /> Q Small Contributor Committee Officeholder Committee <br /> � PoliticalParty/CentralCommittee (AlsoCompletePart7) <br /> 3. Committee Information I.D. NUMBER Treasurer(s) /� <br /> l 2�S�"7ro` � ,�o�/>t N��4 1Crr S`�i�f' <br /> COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) NAME OF TREASURER <br /> J <br /> �� ( %,+C� � ^ - MAILING ADDRESS <br /> ��YYI �'Y1 i � ..J.{� � C ���,^ It.l�-��V190�j� �L z-v �4— `'��� � <br /> <br /> -�� <br /> ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY <br /> e�,�-$-� � �► �� cl�� j .' ��� <br /> MAILING ADDRESS (IF DIFFERENT) N0.AND REET OR P.O. BOX MAILING ADDRESS <br /> CITY STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA CODE/PHONE <br /> OPTIONAL: FAX/E-MAIL ADDRESS OPTIONAL: FAX /E-MAIL ADDRESS <br /> 4. Verification <br /> I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the information contained herein and in the attached schedules is true and complete. I certify <br /> under penalty of perjury under the laws of the State of California that the foregoing is true and correct. <br /> � <br /> Executed on ���a� � gy <br /> D e � S� tureofTreasu rorAssistantTreasurer . <br /> i 1 / <br /> Executed on ` � ��/ � � By � <br /> Date ( Signature of Controlling Officeholder,Candidat ,State Measure Proponent or Responsible Offcer of Sponsor <br /> Executed on By <br /> Date Signalure of Controlling Officeholder,Candidate,State Measure Proponent <br /> Executed on By <br /> Date Signature of Controlling Officeholder,Candidate,State Measure Proponent FPPC Form 460(January105) <br /> FPPC Toll-Free Helpline:866/ASK-FPPC(866/275-3772) <br /> State of California <br />