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Officeholder and Candidate SHORT FORM <br />Campaign Statement - Type or print in ink. Date Stamp <br /> <br />Short Form <br />(Government Code Section 84206) Date of election if applicable: [] Amendment (Explain Below) For Official UseOnly <br /> (Mo~th, Day, Year) . <br /> <br />1. Statement Covers Calendar Year 200__[~. <br /> <br />2. Officeholder or Candidate Information 3. Office Sought or Held <br /> NAME OF OFFICEHOLDER OR CANDID/~'E OFFICE SOUGHT OR HELD <br /> <br /> CITY STAT E ZIP CODE <br /> <br /> AREA CODE/DAYTIME PHONE NUMBEI~ O'~STI~L: FAX / E-MAIL ADDRESS <br /> <br />4. Committee Information <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 /> COMMITTEE NAME AND I.D. NUMBER COMMITTEE ADDRESS NAME OF TREASURER <br /> <br />5. Verification <br /> I declare under penalty of perjury that to the best of my knowledge I anticipate that I will receive less than $1,000 and that I will spend less than $1,000 during <br /> the calendar year and that I have used all reasonable diligence in preparing this statement. I certify under penalty of perjury un, der the I~,aws of the State of <br /> California that the foregoing is true and correct. ,~;~,~J~, ~,/ <br /> Executedon !/~:~/ ~_~./~ 4:~--~ By. <br /> DATE SIGN;~'URE OF OFFICEHOLDER OR CANDID/~-E <br /> <br /> FPPC Form 470 (June/01) <br /> FPPC Toll-Free Helpline: 866/ASK-FPPC <br /> <br /> <br />