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$110RT FORM <br />Recipient Committee Type or Print In Ink. $1alement covers period <br />Campaign Statement--Short Form from ~ <br /> . / <br />For use by rccipicnL commillees which have not received a connibutlon or odtcr receipt which through ~ <br />must be ilemized, have not received or m~zle loans, ~nd have no ou~tanding accrued eXl~n.ses or <br />enforceable promises received. Date el Election <br /> If applicable: <br />'Check one el the following boxea to Indicate the lype el statement being filed: IMonth, Day~ Year) <br /> <br /> E] Pre-election Slalement [] Ballot Measure Post-qualilicalion Statement <br /> [] Semi-annual Statement [] Special Odd-year Campaign Report <br /> <br /> E] Supplemental Pre-eleclion Staternoot (ARach a completed Form 495 to Ihis stalemenl.) <br /> [] Termination Stalemen{ (Allach a completed Form 4 t5 lo this slatemenl.) <br /> <br /> , Committee Information <br /> II CommilteeType (checkb~x~s) lslhisaconUollcdcommittee? E]¥es []No Is this a sponsorcd committee? []Yes [3No lsfl~isabmadbascdcommiltee? DYes []No <br /> <br /> III Verification <br /> This committee has not received any contribulions, cumulative contributions or miscellaneous receipts from a single source totaling $100 or more which must be itemized, and <br /> this committee has not made or received loans, and has no accrued expenses or outstanding enforceable promises received. <br /> I have used all reasonable diligeacc in preparing Ihis statcmem. I have reviewed thc statement and to thc be. st of my knowlcdgc.,~hc in fo_.rma~n contained hernia is truc and <br /> complete. I ccrlif:und, c,r penalty of Parjury under thc laws of the State of California that the fo~cgo~.,~corrJJExecuted on ~ 9,Z Al ~~ L~'~ff ~/r. ~ By ~~,~''~1~1~' '~""' ~'fft~'f .~ <br /> An officeholder, eandidatc, or state measure proponent who controls a committee must also verify thc campaign statement. <br /> I have used all reasonable diligence and to thc best of my knowledge the treasurer has used all reasonable diligence in preparing this statement. 1 have reviewed lhc sta~emcot <br /> and ~o the best of my knowledge thc information contained herein is true and complete. ! ccrlify under penalty of perjury under thc laws of thc Stale of California that Ibe <br /> foregoing is Iruc and correct. <br /> <br /> Execuled on At By <br /> <br /> Executed on Al By <br /> <br /> Executed on Al By <br /> I]A1E ClIY ANn STAT E SIGNA1URE OF OI-FICEI IOLF~. R. CANC4UAI E. OR PllOf~3tlE N ! <br /> <br /> FOR INFORMATION REOUIREO TO BE PROVIDED TO YOU PURSUANT TO TI IE INFORMATION PRACTICES ACT OF 1977. SEE I~ORMATIGN MAI~ :Al CN CAMPAIGN D I .e~.t OSIJRE PflOV1SIGNS OF IHE P(~ LTICAI REFORM AC~ <br /> <br /> <br />