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OITY CLERK DEPARTHEHT I ON(; F()I~ M <br />Officeholder, Candidate, ~.. or ~,~ i. ~.k. ~,~t'~.~ <br />and Controlled Committee <br />Campaign Statement -- Long Form from <br /> ZB 3 <br />(Govc~cm ~ S~s 842~-8421~.5) <br />SEE INSTRUCTIONS ON REVERSE Page.~ <br />Chck ca of Ih Iollowl~ boxe~ Io Indicale I~ lyp ol tlalanl hiq flied: Dale of Election A F~ Ollicial Use Only <br />~ Pre-elecli~ Slalem~l II applicable: <br />~ ~pple~nlal Pre-elecli~ Slalemenl (Allach a compleled Form 495 Io Ibis slalem~l.) (Monlh, Day, Y~a~ <br />~ ~mi-annual Stal~enl <br />~ Term~alDn Slal~ent (Altach a c~plet~ ~rm 415 to Ihis slat~enl) . <br /> <br />I Oflice~lder~ Candidale~ II Other Commillee~ Nol I~luded in Ihi~ ~laleant= L~ ~ ~r <br />and Controlled Co~ittee c~ittees ~t i~l~ed ~ th~ c~olMated stme~m t~ ~e co~rol~d ~ you a~ ~y <br />Incl~ed in this State--hr c~i. ees of w~ch you ~ ~ledge f~t are pri~ily f~d to receive co~ributio~ or <br />~ ~ ~ ~~ ~ C~E: to ~ ~e~itures on be~of~ur c~Ma~. <br /> <br /> CITY SUTE Z~ ~ ~ C~l~ ~ C~IIIEE ~E~: (~ ~D SI~) <br /> CJ~EE J~: ~ ~ . ~ ~ I ID J CITY STATE Z~ ~C~IUE Ptt~E <br /> <br /> C~I~EE ~E~: (~ ~STRE~) <br /> <br /> ~NT ~E~ ~ T~R: (~ ~SlEfl} CflY STATE Z~ ~ C~IME Pt~E <br /> <br /> CITY STATE Ze ~ ~ ~ ~ <br /> Attach add~io~! ~or~ on ~proprimely ~ c~i~i~ s~ets. <br /> <br />III Verification Officeholder or Candidate: <br />Treasurer: I have used aU reasonable diligence and to thc be. st of my knowledge Ihc treasurer has <br />i havc used all rcasonablc diligcncc in prcparing this statement and to thc best of my used all rcasonabic diligcncc in prcparing this slatcmcm. [ have reviewed thc stale- <br />knowledge thc information containcd herein and in thc auachcd schedules is truc and mcnt and to thc hcst of my knowlcdgc thc information contained herein and in thc <br />complete. ! certify undcr penally of pcrjur~ undcr thc laws of thc Stab: of California attachcd schcdulcs is truc and complete. ! certify under pcnalty of perjury undcr thc <br /> that thc forcgoingAs tn~ and corrcct. // . / <br /> Execuled on ~,/'~_,/~ Al / ~ ~//, ~ E xeculed onlaWs of the Stale~be/~of Cali[ornia ,ha,At ,hc/~,Z~/.~,~forcgoing is line ~/'and cch'cci. <br /> <br /> E - '~IG~ATLIRE OF OFFIC£HI~DER OR <br /> <br /> FOR INFORMAIlOt, t REQUIRFD 10 B£ PR©VIE)ED IO YOU I~)RSUAN! IO IHF INFORMAIION PRACIICE$ AC! OF 1911, RE INFORMATION MANUAL ON CAMPAIGI'J DISCLOSURE PROVISIONS OF <br /> <br /> <br />