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01TY 0LERK OEPARTHEHT LONG FOAM <br />Officeholder, Candidate, TVp- or Print in Ink. Slatemont covers period It{~Gi:l~S~amp <br />and Controlled Committee ~ ~ ~ <br />c__..,.n st.t--.-- For-- ,.o. <br />SEE INSTRUCTIONS ON REVERSE Ihrough ' P~g~ __ ol __ <br /> C~:k ~ ~! I~ follo~i~g boxll I~ i~i~ll I~ lyp~ ~! iI~l~m~nl b~ing Iill* D~I~ ~1 fllclio~ ~ A F~ OHicial Use Only <br /> ~ Pre-elecl~ Slatem~t il applicable: <br /> ~ ~pple~ntal Pre-elecli~ Slatem~l (Atla~ a ~mpleted Form 495 to this slatem~l.) lUonth, Day. Year) <br /> ~mi-~ual Station, ~ <br /> ~ Term~a~n Slal~ent (Ntach a ~plel~ ~rm 4 t5 to Ibis stal~enl.) <br /> <br />I Officeholder~ Ca~didate~ II Other Committees Not Included in this State--at= LJs~ ~y o~h~r <br />and Controlled Co~ittee c~ittees ~t i~l~ed ~ lhh c~olidated state~ t~t are comrolled by you a~ ~y <br />Includod in this $talo~nt c~iltees of which you ~ve ~iedge ~hat ~e pri~ily f~d ~o receive co~ributio~ or <br /> ~~~TE: ~ ~ , to ~ ~e~itures on beha~ of your ca~ida~. <br /> <br /> ~ ~ * A - / ~ '- ~ STATE . Z~ ~ ~b C~ITIEE ~E~: (~ ~DSTRE~) <br /> <br /> ~ I I O ~R CIIY STALE ZiP ~ ~ CO~IME PII~E <br /> <br /> ~ ~: ~ST~) <br /> <br /> ~ ~ T~R: C~I~EE ~E~: (~ ~O ST~) <br /> ~NI ~ ~ l~E (~. ~ SIE~) CIIY 51AIE Z~ ~ C~IME PI~E <br /> <br /> SLATE Z~ ~ ~ ~ ~ <br /> A.nc~ ~Sitio~t ~or~don on npproprim~ly ~bgl~ comi~mi~ she~;s. <br /> <br /> Ill Verification Officeholder or Candidata: <br /> Treasurer: I have used all reasonable diligence and to iht best of m? knowledge the treasurer has <br /> ! have used all reasonable diligence in preparing [his statement and to thc best of my used all reasonable diligence in preparing this statement. I have reviewed thc stare- <br /> knowledge thc information contained herein and in the auached schedules is true and mcnt and lo thc best of my knowledge thc information contained herein and in the <br /> complete. ! certify under penally of perjury under thc laws of [he State of California a,ached schedules is uuc and complete. I certify under penalty of perjury under [he <br /> that thc forcgoing is Uiuc and, correct. ~, , . laws of thc Stale of California that thc foregoing is true and correct. <br /> <br /> / . ~ ,~,//~kT£ ~ L,j CITY AND S1AIE i3,AT£ c{rYANOSTATE <br /> <br /> By S~IURE OF TREASURER By <br /> -/N~~'~/~ . S iCd~IATURE OF OFFICE*tOt DER OR CANDIDATE <br /> <br /> FOR INFORMAIIOH REQUIRED TO BE PROVIDED TO YO~J PURSUANT TO TItE INFORMATION PRACTICES ACT OF 1977. SEE iHFOflMA[[O~ MANU2U_ON CAMPAIGH DISCLOSURE PROVISI~ OF Ii IF POLl1 lC.AL [P:f!O[tM &C [ <br /> Slate o! Calilornla Fair Political Practicos Commission. <br /> <br /> <br />