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OFFICEHOLDER AND CANDIDATE <br />Officeholder and Candidate STATEMENT OF TERMINATION <br />Statement of Termination DateStamp <br />This form must be completed by officeholders and WHERE TO FILE: <br />candidates that are eligible to terminate pursuant Officeholders and candidates must file <br />to <br /> Government <br /> Code <br /> Section <br /> 8421 <br /> 4. <br /> Form 416 with the filing officer with <br /> whom they filed their original campaign <br /> Type or print in in.k. statements (Form 470 or 490). <br /> <br />I Officeholder or Candidate Termination II Office Soughtor <br /> NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD FOR WHICH YOU ARE FILING THIS STATEMEN¥ <br /> <br /> RESIDENTIAL OR BUSINESS ADDRESS f NO. AND STREET JURISDICTION (IF APPLICABLE) I DISTRICT NUMI~ER (IF APPLICABLE) <br /> I <br /> CITY STATE ZIPCODE ~t. III Effective Date of Termination <br /> ~,/V~ C~'~[C) '~ ~ C~(,~'~ ~) DATE FLUNG OBLIGATIONS WERE COMPLETED <br /> AREA CODE/DAYTIME PHONE NUMBER <br /> <br />IV Verification ' <br /> <br /> For the office listed in Part II of this form, I verify that: <br /> <br /> A. do not hold or am no longer a candidate for the office; <br /> B. have ceased to receive contributions and make expenditures; <br /> C. do not anticipate receiving contributions or making expenditures in the future; <br /> <br /> D. have eliminated or I declare that I have no intention or ability to discharge all debts, loans received, and other obligations; <br /> E. have no surplus campaign funds; and <br /> F. have filed all campaign statements required by the Political Reform Act disclosing all reportable transactions. <br /> <br /> I have used all reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the information contained <br /> under the laws State of ~alif~/~.t. hlt~,,~i true ~nd iorrect- <br /> herein is true and complete. I certify under penalty of perjury of the <br /> <br /> Executed on I; IJA~ l ~/,~' At ~*~~4 <br /> CITY AN IDATE <br /> <br /> FOR INFORMATION REQUIRED TO eE PROVIDED TO YOU PURSUANT TO THE INt~ORMATION PI~,CTICES ACT OF 1977. SE E INFORMATION MANUAL ON CAMPAIGN DISCLOSURE PROVISIONS OF THE POLITICAL REFORM ACT, <br /> <br /> State of California Fair Political Practices Commission <br /> <br /> <br />