Bain 10-21-1995 thru 01-27-1996 Termination 490

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1 ___. ___.___Officeholder,_ ___Candidate, Typ,or print in ink. COVER PAGE- LONG FORM · Statement covers period Date Stamp and Controlled Committee . ._ vd,..,.,,,, Campaign Statement --Long Form ,,om~ g I~ I'g ,Government Code Sections B4200-84215.5, ,~k II0 -' '" SEE INSTRUCTIONS ON REVERSE through fi: ,! ii ll ~ Supplemental Pre41~ion Statement (ARach a completed Form 495 to this statement.) ~ ~ ~1 . tatement: Included In t tatement c~m~ees~ti~l~dint~c~at~nate~m~tarec~eolledb~a~an~ NAME OF OFF~EHO~ER OR ~AIE c~m~ees of w~ch ~ou ~ve k~e that a~ ~aH~ f~m~ to receive c~tri~i~ · ~ to make executes ~ ~of~r I MMDE~ ~ IU~S AD. SS (K. AND ST~ ~ME M T~A~R C~TR~LED CMM~EE? ~Y STATE ZIP C~E A~A C~AYT~E ~ C~M~EE ~RESS (NO, AND ST~ I.D. ~IER ~ STATE -~ 0 n C~M~EE ~E I LO. NUMIER I CMM~E[ ~D~SS (NO. AND ST~ET) ~Y STATE ~ C~ A~ C~AYT~[ ~E ~E ~ T~R C~ROLLED C~M~EE? ~ANE~ ~SS M T~A~R 1~. AND ST~ET) ~ STATE III Verification , I have u~ iii rlawna~ diligence in preparing this ~atement. I have reviM~ the ~atement and tothe ~fl of my knowle~e the information contained herein Ind in the I~lched Kh~ul~ / DATE ~ ' ~Y AND STATE ~ ~TU~ ~ TMA~R An officeho~ m ~te w~ contrMs · comm~ee mu~ llso verify t~ clm~ign sgteme~. I have u~ ~11 reachable diligence ~nd to the ~ of my kn~ledge the treasurer has used all reasonable dilige~e in pre,ring this ~atement. I h~ve reviewed the statement ~nd to the ~ of my kn~ledge the information cont~in~ herein ~nd in the ~ch~ ~hedules is true and complete. I ce~i~ un~r ~ngffy of ~rju~ under the I~ws of the State~f ~l~fmnia that the foregoing is true and corr,. CflY AND STATE S~TU~ Of ~NDIDATE~FKEW~R Executed on At By DATE ~Y AND STATE S~TU~ M Executed on At By DATE C'Y AND STATE SIGNATURE ~ FOR INF~AT~N M~I~D TO BE P~OVIDED TO Y~ PURSUANT TO THE ~FOMAT~ P~ES A~ Of Ig77, SEE INFO~ATION MANVAL ~ ~MPAIGN DI~LOSUR[ PROVISIONS M THE POLfl~L REFORM A~.