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did <br />Officeholder, Can ate, Tv..or print in ink. COVER PAGE- LONG FORM <br />and Controlled Committee Statement covers ..dad Date Stamp <br />Campaign Statement -- Long Form <br />(Government Code Sections 84200-84216.S) <br />SEE iNSTRUCTIONS ON REVERSE I /'~ <br />Check erie ef the follewin~ Imxel to indkate the t¥.. of statement being filed: Date of election if E <br />8 Pre-election Statement (MOflth. O.y,V..,! JAN 3 I ~J6 For Official UseOnly <br /> Supplemental Pre-election Statement (Attach a completed Form 495 to this statement.) <br /> Special Odd-Year Campaign Report <br /> Semi-annual Statement CJ'; =f <br /> Termination Statement (Attach I Completed Form al S to this statement.) <br /> <br /> tatement: u. any o/he, <br /> Inclu~ s Statement commatees not Included/n t/ds como//datedstatement that are controlled byyou and any <br /> NAME OF OFFICEHOLDER OR CANDIDATE ¢onun~ees of eh/ch you have knmededge that ere pdmar//y fanned to receive contributiom <br /> <br /> C~MMnTEE ~ I.D. NUMIEI <br /> OFFICE f~UGHT Ol HIM} ~II~.UD~ LIX. ATION AND DI~TIICr nUMREI · AII'FLICAILE) <br /> <br /> REMOENTN Gl BUSINESS aSS (NO. AND STREET) MAIdl Of TR~.MJRE R CONTROLLED COA4MITTEE1 <br /> ~ STATE ~ COf~ CoMMa'Es ADDIESS lng. AND STlELrl) <br /> <br /> COMMITI'EE NAME ~l~l.O. II#~l~l ~ C~ STATE <br /> u , mo --I ssi/so ,,.o..... <br /> I COMMIITEE ADDIESS lng. ~ STREET) I <br /> <br /> cn'Y STATE ~1t COO~ ~ C_m~- --~EMYTIME FflOI4 ~ ~ TREASURER CONI'RO~LED COMMIll'EET <br /> <br /> ~N~E OF TREA$URER ......... CQIdldlTTIS iix)mss Ino. A.~ StreeT) <br /> INO. ANO III[ET) ~ STATE <br /> <br />III Verification <br /> I hive used ell realoneble diligence in preparing this statement. I hive reviewed the statement and to the best of my knowledge the Inlocmntion contained herein and in the attached schedules is <br /> ' true 'nd c°mp *le*tlL I ce/tify under Plnalty °f perjury under the I'ws °f the Stated__~lif°rni" tlmt the kxe~c~ng' tru~.nd~c°rr'* .~- ~_~ <br /> <br /> ' d~ti - ' (TTY AJm STATE S~GN~TURE Of <br /> <br /> An offic,e,ho?, r of clnd~dlte who c. ontrob a committee must alsQ verify the cempai.gn statement. I hive used ell reasonable dil~ence and to the best of my knowledge the treasurer has used all <br /> reaso.naD,e omoenct m prepareo tl~s statement. I hive reviewed the statement end to the best of my knowledge the iflfoq~)~t~)n cs)ntaine~d~herein ~ in ~ schedules is true and <br /> complete. I certif~ un~,r pennlty of perjur/u~nder the I~vvs of the State of California that the foregoing is true end correcl~/ / // · // <br /> <br /> Executed on At By <br /> D~T! OTY Am) STATE S#mATU~ O~ <br /> <br /> Executed on At By <br /> DATE CiTY A~de) STATE SIG~KTUP,~ Of cANO#)&IUofflCIHOLDtl <br /> <br /> FC)~ INFC)4~IATIofd IIQUN~ll) TO Ii I~l~vIOII) To YOU PUISUANT TO Till I~FOIMATION PIACTKI$ AC~ of ~STT. ~! .INFdl~.~AT~# MA.~N~A_L ~ _CAMPAIGN D~SCLOSUR! .P#_OV!.s ~K~...S ~of THE POLftlCAL ~EFORM ACt <br /> <br /> <br />