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Officeholder, Candidate, Typeor print inink. COVER PAGE- LONG FORM <br />and Controlled Committee Statement covers period I DateStamp <br />Campaign Statement -- Long Form from/ / / / ~'' ' .... 12 <br />(Government CodeSectionsB4200-84216.5) - - I <br />SEE INSTRUCTIONS ON REVERSE ' ' I I U ! i-F -~ ~ I Pa~ <br />Check one ~ the following ~xes to i~icate the ty~ of statement ~ing flied: Date of ele~ion ~ applica~ ~ I -- , ~ ',',, ! <br /> Pre~le~ion Statement (Month, Day. Year) II il I~1 ~ 9 19~ "~,' 1' <br />~ Supplemental Pre~le~ion Statement CA. ach a completed Form 495 to this statement.) <br /> <br />~ Semi-annualStatement // <br />~ Termination Statement CA.ach I completed Form ~15 to this ~atement.) <br />I, ~ff~(eholder. Candidate, and Controlled Commi~ee IIOther Committees Not Induded in this Statement: <br />Included in this Statement comm~ees not i~lu~d in this consolidated ~atement that are controlled by you a~ any <br />NAME OF OFFICEHOLDER OR ~N~DATE comm~ees of whkh you have knowle~e that a~ pHmarily formed to receive c~tri~i~ <br /> ~ to make ex~ures on ~haffofyour ca~a~. <br /> <br /> ~[ SOU6~ OR HELO (I~LUD[ L~T~N AND OlSTRI~ NUMIER IF APPLI~IL[) <br /> <br /> C.IWxl CO0~ClL <br /> ~SlDE~IAL OR BU~NE$$ ADD.SS (NO. AND STREE~ NAME ~ TREASURER CONTROLLED C~M~EE? <br /> <br /> C~Y STATE ZIP CODE A~A C~E~AYTIME PHONE C~M~EE ADDRESS (NO. AND <br /> <br /> COMMI~EE NAME ' I i.D. NUMIER ~ STA~[ ZIP CODE A~A COD~AYTIME <br /> 194 ~003 <br /> <br /> I C~M~EE ADDRESS (NO. AND ST~ET) <br /> C~Y STATE ZIP CODE A~A CODE~AYTIME PH~E ~ME OF T~ASU~R C~ROLLED C~M~EE? <br /> NAME OF TRE~URER C~M~[[ ADD.SS {NO. AND <br /> PE~NE~ ADD. SS ~ T~ASU~R (NO. AND ST~E~) C~Y ~TA~E ZIP CODE ~EA C~AYTIME <br /> C~Y STATE ZIP C~ A~A CODE~AYTIME ~E <br /> <br />III Verifi{ation <br /> I have u~d all reamnable diligence in preparing this statement. I have reviewed the statement a nd to the ~ of my~n~ge the infor~tion cont~d herein a~ in the a~ached ~hedules is <br /> true and compl~e. ~ce~i~under~na~f~rjuryunderthe~aws~ftheState~f~a~if~rniathatthef~reg~ingis~uea~c~re~. ~ _~ / / ~ _ __ /] <br /> <br /> An officeholder m ~idate who ~ontrols a comm~ee must also ver~y t~ campaign statement. 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 knowledge the information contained herein and in the a~ached schedules is true and <br /> complete. I ce~i~ under ~nalty of ~rju~ under the laws of the State of California that the foregoing is true and cor~_ ~ ~ _ <br /> <br /> Executed on At By <br /> DATE C~Y AND STATE ~IG~AIUR[ OF ~NDIDATE~FI(E~DER <br /> <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE OF <br /> <br /> FOR INFORMATION RE~IRED TO BE PROVIDED TO YOU PURSUANT TO THE INFO~ATION P~ICES A~ O~ 1977, SEE INFORMATION MANUAL ON ~MPAIGN DISCLOSURE PROVISIONS OF THE POLIII~L REFORM <br /> <br /> <br />