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Officeholder, Candidate, Typeor print in ink. COVER PAGE- LONG FORM <br /> Date Stem Pstatement covers period <br />and Controlled Committee f,om <br /> <br />SEE INSTRUCTIONS ON REVERSE , <br />Check one of the following boxes to indicate the type of statement be"rq~ filed. Date.°_f_eie~i°_nif~:~~--M~-'-'~ ~ ~i~; ,,. ~ ~ .... I'.! ForOfficialUseOnl¥ <br /> <br /> corem/trees of which you have knowledge that a. re primarily formed to receive contributiom <br /> NAME OF OFFICEHOLDER OR C),NI~ATE m' to ,,-:~-~e expend/tums on beha/f off'our canclideq/. <br /> <br /> OFFICE M2U~HT OR HE~D ~I~[UD~ L(XAT. ION AND,~DIST P~ NUM ? R IF APIq'~I'E ) _ <br /> <br /> RESIDENTIAL OR IUMNESS ADD / ~NO. ~ STYE <br /> STATE ZIP ~.~T~ ~ ARE~ ~.Of~JOAYTIME ~ COMMITTEE ADI)I~SS (NO. AND STREET) <br /> <br /> I.D. <br /> COMMITTEE NAME / <br /> <br /> COMMITTEE ADDESS (NO. AND STREET) <br /> <br /> NAME OF TREASURER <br /> <br /> (No. AND <br /> <br /> coy STATE <br /> AttaCh additional Information on appropriately labeled conffnuetion sheet~. <br /> <br /> I have used all reasonable diligence in preparing this/~atement. I have reviewed the statement and to the best of ~n~dge the information contained herein end in the attached schedules is <br /> true and corn plete. )/cert~fy under Penalty of perj~dj~jA'Jnder the lelNr)4)f the Stat))~)~ Califor nil that the f°reg°ing, <br /> ,x.cu, o · ,, ! .. ", <br /> An offlc.e .h o l .d .e r /or Ca i~n~rE~te ~ ~i sn ~: ItS;mC;n~ n ~ h~l;;vee ?e:iste awleS~ ~l~mceL~ Paan~ ~oStt~ tee~" to'f Itoh; ~cen ~wS~q~l~ ~i nn ~bg~a ~~ ' e~?f~l~~eu~ ~:: rt rh;es auns~d all <br /> :~lne~:~.el°c:~i~ynCendePr nPaa g fperjuryund' elawsof.the Calif tn' at the foregoing is true end F~.~f~ /~/~ ///~V/..~ ~_~~ <br /> <br /> Executed on At By $~GNA~URE OF CANOIOATE~OF~:EHOtDER <br /> DXTE CnY *ND S~ <br /> Executed on At By <br /> DATE CnT AND $~TE S~aNA~UaE O~ CRNO~OR~E~EHOtDEe <br /> <br /> ~na ~mna~RT~N ~OUl~O TO SE eeowDEo ~0 ~ou euasuAm TO ~HE INFORM~O~ ~C~ES AC~ O~ ~.. SEE [N~aM~T~ON <br /> <br /> <br />