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Officeholder, Candidate, Type m print in ink. COVER PAGE- LONG FORM <br />· and Controlled Committee Statement covers period Date Stamp <br />Campaign Statement -- Long Form ,,om~ ~ ~ I~ ~ ~! ~ <br />(Government Code Sections 84200-84216.5) <br />SEE INSTRUCTIONS ON REVERSE through- ~ :/,~-I~RI <br /> Check one of the folk)wing boxes to indicate the type of statement being filed: Data of election if applical~e: <br /> B Pre-election Statement (Month, Day, Year) ~; (~l~tt,~.~ For Official Use Only <br /> <br /> Supplemental Pre-election Statement CA,tach a completed Form 495 to this statement.) CI'rY~ ~'~- ......... Fir~Wr',~'~ ...... CITY <br /> Special Odd-Year Campaign Report C!TY CLERK <br /> Semi-annual Statement <br /> Termination Statement (Attach 4 completed Form 415 to this statement.) <br /> LlsY any other <br /> Include tis Statement commtttees nnt includecl in this comoltd~ted sYatement tl~lt are controlled by you and any <br /> NAME OF OFFICEHOLDER OR CANDIDATE come/flees of which you h~ve knowledge that are primarily formed to race/ye contribuCiom <br /> o~ to make expenc~ures on behelf of your canclkY~/. <br /> ,1o0'7 ~t~d~d CO~'~EE~E I ,.D. NU~BER <br /> OFFICE SOUGHT ga HELD (INGUOE LOCATION AND DISTIUCT NUMBER If APPLICABLE) <br /> I <br /> RESIDENTIAL ga JUSff~SS ADDI~SS (NO. AND STREET) NAME OF TREASURER ~ CONTROLLED COMMITTEEt <br /> <br /> C/TY ~ STATE ~P COO~ AI~EA COCIJ~AYI'IIdE PttONE COMMITTEE ADD. SS (NO. ANO STREET) <br /> <br /> COMMITTEE NAME J LD. MUMBER CITY STATE Z~CODE AREA COOEJDAYTIME PHOJ~ <br /> I <br /> COJaMIT/EE NAME J I.D. NUMBER <br />' I COMMITTEE ADD~ESS (NO. AND STREET) <br /> I <br /> CrrY STATE ZIP CODE AREA COOf.~AYTIME PHONE NAME O~ TREASUI~R CONTROLLED COMMITTEE <br /> <br /> NAME OF TREASURER CJii ADO~SS (NO. AND STREET) <br /> PERMANENT ADOlESS OF TREASURER (NO. AND STBEET) CITY STATE ZIP CODE AREA CODE/DAYTIME <br /> <br /> CITY STATE ZIP COOF ABEA COOEa)AYTIME IlqdOHE <br /> <br /> Affach add/t/onellnformation on e~pro/~/afe/y labe/edcontinuation sheets. <br /> <br />III Verification <br /> I have used all reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my k nowlt,~g9 the in.fofmption$on:t-med herein end in the attached schedules is <br /> i true and complete. !cqirtify under penalty of perjury under the laws of ~;,he State of California that the foregoing is tru~La:pertgrfect./~-'~/ ///* _ <br /> <br /> DATE · ~ AND STATE SIGNATURE OF TREASURER <br /> <br /> An officeholder or candidate who controls · committee mud also verify the campaign statement. I have used ell reasonable diligence and to the best of my knowledge the treasurer has used all <br /> reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the information contained herein and in the attached schedules is true and <br /> complete. I certify undlr penllty of perjury under the laws of the State of California that the foregoing is true In, correct. <br /> <br /> DATq[ CITY AND STATE Y t SIGNATURE Of C,~NDIDATE/Of FICEflOLIXR <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE Of CANDIDATFJOFFICEHOLDER <br /> <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE Of CANDIDATE/OFFICEHOLDER <br /> FOR INFOfUdATION REQUIRED TO BE PROVIDED TO YOU PURSUANT TO THE INFOfUdATION PRACTICES ACT OF 1~77. SEE INFORIdATI~H MAN~AL 4~)N CAMPAION DISCLOSURE PROVISIONS OF THE POLITICAL REFQRM A~T. <br /> <br /> <br />