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SHORT FORM <br />Officeholder and Candidate T~--,, mt b bk Wa S~ <br /> <br />Campaign Statement -- Short Form <br />(Govc~nmcm Code Section 84206) <br />For usc by officeholders and candidates who do not have a cofltrollcd commiitcc and who do not anticipate receiving <br />$1000 or marc in contributions and do not anlicipatc spcnding $1000 or mom during thc cmirc calendar year. <br />Of£tccholdcrs whose salary is less than $100 pcr month and judges who have a coattollcd committee may usc this form ~l~ S i [[~ <br />under ccflain ckcumstanccs. Sec thc appropriate Information Manual on Camtaaien Disclosurc Provisions of thc <br />~ (Manual A) for I'urthcr information. <br /> <br /> Statement (~ovm Calendar Year Jg __ <br /> <br />I Officeholder or Candidale I.lem~alio. II Inlo~lio. on Office Held or ~hi <br /> <br /> ~st all co.trees of w~ch you ~ve ~wledge t~t ~e pri~rily for~d o receive contributio~ or o ~e ~it~es on be~ of ~ carney. <br /> <br /> C~Mi~EE ~ AND I.D. NUMBER C~MI~EE AD~E~ ~E ~ TR~SURER <br /> <br /> IV Verification <br /> I declare undcr pcnally of pcrjury that to thc best of my knowledge, l anticipate that 1 will receive less than $1000 and that ! will spend less than $1000 during thc calendar year <br /> and that I have used ali rcasonablc diligcncc in preparing this statemcflt. I certify undcr pcnahy of pcrjury undcr thc laws of thc State of California that thc foregoing is uno and <br /> <br /> State of California Fair Political Practices Commission. <br /> <br /> <br />