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Officeholder, Candidate, /r~ {V16./X.J J~ ~ ~ <br /> ~ COVER PAGE - LONG FORM <br />and' Controlled Committee Type or print in ink. Statement covers period Date Stamp <br /> <br />Campaign Statement - Long Form from -J~.-~. t ) (~j ~ CALIFORNIA490 <br />(Government Code Sections 84200-84216.5) <br /> ~ Page <br />Check one of the following boxes to indicate the type of statement being filed: Date of election if applicable: For Official Use Only <br /> ~ Pre-election Statement (Month, Day, Year) ~~ <br /> ~ Supplemental Pre-election Statement (A,ach a completed Form 495 to this statement.) <br /> ~ Special Odd-Year Campaign Repo~ ~ <br /> ~Semi-annual Statement ~, ~/ /~ <br /> ~ Termination Statement (Attach a completed Form 415 to this statement.) <br />I Officeholder, Candidate, and Controlled Committee II Other Committees Not Included in this Statement: U~..~oth~r <br />Included in this Statement commi~ees not included in this consolidated statement that are controlled by you and <br />NAME OF OFFICEHOLDER OR CANDIDATE any commi~ees of which you have knowledge that are primarily formed to receive <br />G~E~ ~~ contributions or to make expenditures on behalf of yourca~didacy. <br /> COMMITTEE NAME I.D. NUMBER <br /> OFFICE SOU (INCL LOCATION AND DISTRICT NUMBER IF APPLICABLE) <br /> <br /> RESIDENTIAL OR BUSINESS ADDRESS ND ET) NAME OF TREASURER CONTROLLED COMMITTEE? <br /> <br /> CITY STATE ZIPCODE AREA CODE/DAYTIME PHONE COMMITTEE ADDRESS (NO AND STREET) <br /> COMMITTEE NAME ID NUMBER CITY STATE ZIP CODE AREA CODE/DAYTIME PHONE <br /> COMMIT?EE ~DDRESS(NO ~ND STREET) <br /> <br /> CITY ~ STATE ZIP CODE AREA CODE/DAYTIME PHONE O YES ~ NO <br /> <br /> ~A~E OF TREASURER ) ' <br /> <br />PERMANENT ADDRESS OF T~ASURER (NO AND STREET) <br />CITY [~ '~ ~ O ~ ~, SSATE, ''~ZlP CODE~o~ .REA CODEtDAY;IME PHONE~,~0 ,' '--0~'~ Attach additionalinformation on appropriatelylabeledco~ti~uation shee,. <br />III Verification <br /> I have used all reasonable diligence in preparing this slatemenl. I have reviewed the statement and to the best of my knowledge the information contained herein and in lhe a~ached schedules is true and <br /> <br /> ~n officeholder or candidate who controls a committee must also verif~ the campaign statement. I have usoO all roasonable dili~onco anO to tho host o[ my knowled~o tho tmasuror has usod all <br /> reasonable diligence in p[eparin~ this staloment. I have roviewoO lbo slalement and to tho besl o~ my knowleO~o tho in[ormation~ontainod horoin anO in lbo al~acheO scheOulos is true anO complelo. <br /> underpena~ty~f~erjuW~un~erth~aws~fthe~tat&~fC~if~rniathatthef~reg~ingistrueandc~rrect~Execute~n- ~]~/~ At ge~~ ~ C 1~' C~ Bv / ~ ~~ <br /> ¢ DATE/ - CI~ AND STATE,/ } ' <br /> ' SIGNATURE OF CANDIDAT~O~FICEHOLDER <br /> <br /> Executed on At By <br /> DAlE CITY AND STATE SIGNATURE OF CANDIDAT~OFFICEttOLDER <br /> <br /> Executed on At By <br /> DATE CITY AND STALE SIGNATURE OF CANDIDATE/OFFICEHOI DER <br /> <br /> FOR INFORMA]ION REQUIRED TO BE PROVIDED ]O YOU PURSUANT TO THE iNFORMATION PRACTICES ACT OF ~977. SEE INFORMATION MANUAL ON CAMPAIGN OlSC~OSU~ pROVISiONS OF THE POLITICAL ~M <br /> State of California Fair Political Practices Commission <br /> <br /> <br />