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I <br /> <br /> Officeh older, Ca nd idate, Type or print in ink. COVER PAGE- LONG FORM <br /> and Controlled Committee Statement covers period Date Stamp <br /> Campaign Statement -- LongForm from ~,~"//. // /',;::-,~/ <br /> (Government Code Sections 84200-84216.5) <br /> SEE INSTRUCTIONS ON REVERSE through f~c- / i ~ i c:i <br /> ~ck o~ of the following ~xes to l~icate the ty~ of statement ~Ing filed: Date of eleaion ~ applica~e: <br />  Pre~le~ion Statement (Month, Day, Year) <br /> Supplemental Pre~le~ion Statement (A~ach a completed Form 495 to this statement.) ~CT 2 <br /> ~ S~cial Odd-Year Campaign ee~ "':' i.~;, <br /> Semi-annu.lStatement I'~: ,,. ~} I ,:~ ~ <br /> Termination Statement (A~ach ~ completed Form a15 to this ~atement.) <br />  ~r i Gr r-~K / <br /> Offtceholder, Candldate, and Controlled Committee II Other Committees ot Ihtl0'*~eO~~~ent: Lmanyot~r <br /> Included in this Statement commt~ees not i~lu~d in this comolidated natement that are contr~led by you a~ any <br /> NAME OF OFF~E HOLDER OR ~N~ATE comml~ees of which you have knowle~e tha~ are primarily f~med to receive contri~i~ <br /> .~_/~ ~[ ~. ~ ~ ~ tO make expOSures on ~haff of your ca~. <br /> <br /> ~F~[ ~ ~ HEW ~U~ t~T~ AND DIST~ NUMBER f AffL~ILE) C~M~EE ~ME I.D. NUMBER <br /> <br /> (~. AND ST~E~ / ~ME ~ T~ASU~R <br /> ~ C~TROLLED C~M~EET <br /> <br /> ~Y ~TATE ~ C~E A~A C~YTIME ~E C~M~E[ ADDRESS (NO. AND ST~) <br /> <br /> COMMI~EE NAME ' <br /> ': -. ~: , J 1.0. NUMIER C~ STATE ZIP C~E <br /> I C~M~EE ADD. SS (~. A~ ST~ET) I LD. NUMIER <br /> I <br /> C~ . ~ STATE ZIP C~E A~A CO~AYTIME ~[ ~ME ~ T~A~R C~TROLLED C~M~EE? <br /> <br /> NAME O[ TRE~URER ~ I ~ - c~a~..o~ss <br /> ~ANE~ ~$S ~ T~ASU~R (NO. AND ST~ET) C~Y STATE ZIP CODE AREA C~AYTIME <br /> ~Y ~TATE ZIP C~ A~A CODE~AYTIME ~E <br /> <br />III Verification ' <br /> I have u~d all reachable diligence in preparing this statement. I have reviewed the statement and to ~he ~ of my knowledge the information contained herein and in the a~ached schedules <br /> i trueE~uted onand complete./~l ce~i~under/~'~na~At of ~rjury,~under ~(the laws o~he~ t~State of ~Calif°rnia~ that ~ the foregoingBy is true and corre~. <br /> / DATE / ~ CITY AND STATE / / ~ SIGNATURE ~ T~SU~R <br /> An officeho~er m ~idate who controls a comml~ee must also verify the campaign statement. I have used all reasonable diligence and to the ~st of my knowledge the treasurer has used all <br /> reasonable dilige~e in pre,ring this statement. I have reviewed the statement and to the ~ of my knowledge the information contained herein and in ~he a~ached ~hedules is true and <br /> complete. I ce~i~ under ~n.l~y of ~rju~ under ~he I.ws of the State of C.lifornia that the foregoing is true.nd corre~.Executed on /~/2?, ~/~ At ,~'0~-~ ~ /~,, / ~/~ ~ By -=~ /~ <br /> DATE ' C~Y AND STATE ~/ SIGNATURE OF ~NDIDATE~FF~[~D[R <br /> Executed on At By <br /> DATE C~Y AND STATE SIGNATURE OF ~NDIDATE~FFICE~DER <br /> Executed on At By <br /> DATE CITY AND STATE ~IGNATURE OF CANDIDATE/OFFICEH~DER <br /> FOR INF~AT~ ~I~P TO ~E PROVIDED TO YOU PURSUANT TO THE INFO~AT~N P~O~[S A~ OF 1977, SEE INFORMATION MAN~AL 0N ~MPAIGN DISCLOSURE PROVISION~ OF THE ~LITI~L REFORM ACT <br /> <br /> <br />