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OFFICEHOLDER AND CANDIDATE <br />Officeholder and Candidate STATEMENT OF TERMINATION <br />Statement of Termination <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 use Only <br />to Government Code Section 84214. Form 416 with the fill ng officer with <br /> whom they filed their original campaign <br /> Type or print in ink. statements (Form 470 or 490). <br /> <br />I Officeholder or Candidate Termination II Office Sought or Held <br /> NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD FOR WHICH YOU ARE FILING THIS STATEMENT <br /> <br /> RESIDENTIAL OR BUSINESS ADDRESS NO. AND STREET JURISDICTION (IF APPLICABLE) I DISTRICT NUMBER (IF APPLICABLE) <br /> I <br /> CITY STATE ZIP CODE <br /> /~]~:::c:~ ~r~ ~ ~,~f~/.~ ~ III Effective Oate of Termination <br /> AREA CODE/DAYTIME PHONE NUMBER DATE FILING OBLIGATIONS WERE COMPLETED <br /> <br />IV Verification <br /> <br /> For the office listed in Part II of this form, I verify that: <br /> <br /> A. I do not hold or am no longer a candidate for the office; <br /> <br /> B. I have ceased to receive contributions and make expenditures; <br /> <br /> C. I do not anticipate receiving contributions or making expenditures in the future; <br /> <br /> D. I have eliminated or I declare that I have no intention or ability to discharge all debts, loans received, and other obligations; <br /> <br /> E. I have no surplus campaign funds; and <br /> <br /> F. I 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 /> herein is true and complete. I certify under penalty of perjury under the laws of the State of California that the foreg~g~s_ true an~d correct. <br /> <br /> fOR INFORMATION REQUIRED TO BE PROVIDED 10 YOU PURSUANI TO THE INFORMATION PRACI'ICES AC! Of 1gl7, SEE INI:ORMATION MANUAL ON CAMPAIGN DISCLOSURE PROVISIONS OF THE POLITICAL REFORM ACT. <br /> <br /> State of California Fair Political Practices Commission <br /> <br /> <br />