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Officeholder a nd Candidate Ty.e or print in Ink. SHORT FORM <br /> Date Stamp <br />Campaign Statement -- Short Form <br />(Government Code 5ecbon 84206) <br /> <br />For use by officeholders and candidates who do not have a controlled committee and who do not anticipate <br />receiving $1,000 or more in contributions and do not anticipate spending $1,000 or more during the <br />calendar year. Officeholders whose salary is less than $100 per month and judges who have a controlled J~ <br />committee may use this form under certmn circumstances. See the Information Manual on Campaiqn <br />Disclosure Provisions of the Political Reform Act for Elected Officeholders, Candidates, and Their Controlled <br />Committees for further information. <br /> <br />I Statement Covers Calendar Year 19 <br /> i <br />II Officeholder or Candidate Information III Information on Office Sought or Held <br /> NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD <br /> <br /> RESIDENTIAL OR B USI~,kIE SS ADDRESS ~-/~-TREET) JURISDICTION (LOCATION) I (IFDISTRICTAPPLICABLE)NUMBER <br /> I <br /> CITY STATE ZIP CODE DATE OF ELECTION (MONTH, DAY, YEAR) (IF APPLICABLE) <br /> <br /> AREA CODE/DAYTIME PHONE NUMBER <br /> <br />IV 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 NAM[ ANPl p NUMBER (:OMMITTE[ AppRl~;~; NAME OF TREASURER <br /> <br />V Verification <br /> I declare under penalty of perjury that to the best of m~ knowledge, I anticipate that I will receive less than $1,000 and that I will spend less titan $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 under the laws of the State of <br /> California that the foregoing is true and correct. <br /> <br /> DATE ' ClT'f AND STATE ~ SIGNATURE OF OFFICEHOLDER OR ~ND(¢E <br /> <br /> FOR INFOR~AIlON fl[ QUIRf D TO BE PROVIDED TO YOU PURSUAN1 IO THE INFORMATION P~ICE5 ACT OF lg77, SEE INFORMATION MANUAL ON CAMPAIGN DISCLOSURE PROVISION5 OF THE ~LITI~L REFORM A~ <br /> State of Califmnia Fair Political Practices Commission <br /> <br /> <br />