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COVER PAGE <br />Recipient Committee Type or print in ink. Date Stamp <br />Campaign Statement <br />Cover Page " ~ i)~ <br />(Government Code Sections 84200-84216.5) ~ <br /> I Statement c°vers peri°d IDate °felectl°nifapplical~ll~"~from~"~/--~ (Month Day Year. , ) ~{,~ ~ JAN 2 <br /> ~ Offic,~oldor, GanOidata Controll~O Gommitta* ~ Bellot Moasuro Gommitta~ ~ ~rooloction Stat*m~nt ~ Oua~orly Statamont <br /> ~ Stata Gandidato [l*ction Gommittao 0 ~rimarily FormoO ~ Somi-annual Statemont <br /> ~ Ro~II ~ Gontroll~O ~ l~ination Statoment <br /> (~soC~pletePa~51 ~ Sponsored <br /> (AtsoC~tePa~6) ~ Amendment (Explain below) Statement-Attach Fo~495 <br />  General Pu~ose Committee <br /> ~ Sponsored ~ Pdmadly Formed Candidate/ <br /> ~ Small Contributor Committee Offi~holder Committee <br /> ~ Political Pady/Central Committee (Al~m~etePa~7) <br /> <br />3. Commi~ee Information I,.o. NUMBER ~ ~ Treasurer(s) <br /> <br /> NAME F TREASURER <br /> <br /> M IF O. AND STREET OR P.O. BOX M ESS <br /> <br /> CITY STATE ZIP CODE AREA CODE/PHONE CITY STA~ ZIP CODE AREA CODE/PHONE <br /> <br /> OPTIONAL: FAX / E-MAIL ADDRESS OPTIONAL: FAX / E-MAIL ADDRESS <br /> <br />4. Verification <br /> I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge~e information contained herein and in the attached schedules is tree and complete. I <br /> certify under penalty of. pe[~ury under, the laws of the State of California that the foregoing is tree and correct/I,~ <br /> <br /> Executedon T [>~ By ' . It <br /> <br /> Executed on By <br /> FPPC Toll-Fr~ Helpline: 8661ASK-FPPC <br /> S~te of California <br /> <br /> <br />