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SHORT FORM <br />Officeholder and Candidate Typeoi, Prlntinlnk I Dale$1amp <br />Campaign Statement -- Short Form <br /> <br />For use by officeholders and candidales who do riel a &.not ~_ticipate t~. <br /> liT.t: <br />Officeholders whose sala~ is less than $100 per month and judges who have a conuolled commiUee may use this fo.l~[i .! !bM <br />under certain circumstances. See the appropriate ll~formalion Manual on Campaign Disclosure Provisions of the~'--~ <br /> <br /> Stalemenl covers Celendar Year 10 C~/ . <br /> <br />I Officeholder or Candidate Information II Information on Office Held or Sought <br /> <br /> STATE ZIP CODE DATE il~ ELECTION (MONTH, D~Y. YEAR) (IF APPtlCABLE) <br /> <br />III Committee Inlormation <br /> List all committees of which you have knowledge that are primarily formed to receive contributions or to make expenditures on behalf of your candidacy. <br /> <br /> COMMI1D'£F: NAME AND I.D. NUMBFR COMMI'D'EF ADDRESS NAM£ OF: TREASURER <br /> <br /> IV Verification <br /> I declare under penalty of perjury that to thc bcst of my knowledge, 1 anticipate that I will rcccivc less than $1000 and that I will spend less than $1000 during thc calendar year <br /> and that i have used ali rcasonablc diligence in preparing this statement. I certify under penalty of perjury under thc laws of thc State of California that thc forcgoing is truc and <br /> ¢OITgCL <br /> <br /> ] CJIY/~ SIAIE (~ . ,~GNATUI~ OF OFFIC[IIO~DEfl ~ CANDIOAI*E <br /> <br /> FOffi INr-ORMATION FIFO .UIR£D TO BE PROVlE~D TO YOU PURSUANT TO THE INFORMATION PRACTICES ACT OF 1977, S~E IFIfO~MATION MANUAL ON CAMPAIGN OISCLOSURE PROVISIONS O~ THE POLITICAl REFORM ACT. <br /> <br /> Stats of California Fair Political Practices Commission. <br /> <br /> <br />