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Officeholder, Candidate, Type or print in ink. COVER PAGE- LONG FORM <br /> and Controlled Committee Statement cover~ period Date Stamp <br /> Campaign Statement-- LongForm from / / / / <br /> SEE INSTRUCTIONS ON REVERSE through/.~>/---~/g~---_ <br /> C~ck one of the following ~xes to i~icate the ty~ of statement ~ing filed: Date of e~ion ~ applicaMe: , ~ <br />  For Official U~ Only <br /> P[e~le~ion Statement (Month. Day. Year) ~ · <br /> ~ Supplemental Pre~le~ion Statement (A~ach a completed Form 4~5 to this statement.) <br /> ~ Semi-annual Statement // ~ ~ ~ <br /> ~ Termination Statement (A~ach i completed Form 415 to this ~atement.) - ~ ~' ~ F ..~ : :~ t <br /> Officeholder. Candidate, and Controlled Commi~ee II Other Committee ~ ~~ i~:th~atement: <br /> I n cI u d · d i n t h i s S ta te men t comm~ees ~t i~l~d in this comolida ted ~atement ~a t are controlled by you a~ any <br /> NAME OF OFFICE HOLDER OR ~NMOATE comm~ees of which you have knowle~e that a~ primarily formed ~o receive contri~i~ <br /> ~[~ E ~/~ ~ ~ ~ tO make ex~itures on ~Nofyour <br /> <br /> _ C~M~EE NAME I.D. NUMBER <br /> ~FICE SOUG~ OR HELD (I~LUDE L~T~ AND DISTR~ NUMIER IF APPLI~BLE) <br /> <br /> RESID~L ~ BU~NESS ADD. SS (NO. AN~ ST~E~ ~ME ~ T~ASU~R C~TROLLED C~M~EE? <br /> ~Y ~TATE ZIP CO~ A~A ~AYTIME PH~E . C~M~EE ADDRES~ (NO. AND ST~) <br /> <br /> I C~M~EE ADD.SS (NO. AND ST~ET) <br /> C~ STATE ZIP C~E A~A C~E~AYTIME ~E ~ ~ME ~ T~U~R C~ROLLED <br /> NAME OF TRE~URER C~M~EE AD.SS (~. AND <br /> PE~ANE~ ADD.SS ~ T~ASU~R (NO. AND ST~ET) C~ STATE ZIP CODE A~A C~AYTIME ~E <br /> <br />III Verifi{ation <br /> <br /> true and complete. ~e~i~nder~na~f~r~ryunderthe~aws~ftheState~f~a~f~rniathatthef~r~ingistru~dc~rre~ ~ ~ ~, <br /> <br /> I DATE; ' CITY AND STAT( ~" ~ SIgNaTURE OFTREA~R <br /> <br /> An officeho~er m M~ldate who controls a comm~ee must also verify t~ campaign stateme~. I have used all reasonable diligence and to the ~st of my knowledge the treasurer has used all <br /> reasonable diligence in pre.ring this statement. I have reviewed the statement and to the ~ of my kn~ledge the information contained herein and in the a~ached schedules is true and <br /> comp,ere. , ce~i~ under ~na,ty of ~rju~ under the ,.ws of the State of C.,iforn,a th,t the foregoing is true ,nd corre~. ~Executed on ~/~ (~A~' ~ At ~~~cnY AND ~STATE ~// ~ ~ By ~ SIGNATURE~OF CANDIDATE~CE.DER <br /> Executed on At By <br /> DATE C~IY &ND S/AlE SIGNATURE OF CANDIDATE~FFICE~DER <br /> <br /> Executed on At By <br /> DATE CITY AND STATE SIGNAIURE Of CANDIDATE~FF~CEHOLDER <br /> <br /> FOR INFORMATION RE~IRED TO BE PROVIDED TO YOU PURSUANT TO THE INFORMATION P~ICES A~ OF 1977. SEE INFORMATION MAN~AL ON ~MPAIGN DISCLOSURE PROVISIONS Of THE POLIII~L REFORM <br /> <br /> <br />