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Officeholder, Candidate, Typeor print in ink. COVER PAG E- LONG FORM <br />and Controlled Committee Statement covers period Date Stamp <br />Campaign Statement -- Long Form f,om <br />(Government Code Sections 84200-84216.5) <br /> <br />SEE INSTRUCTIONS ON REVERSE Page <br />Check one of tho following boxes to indkate the type of statement being flied: Date of election if I <br />fi Pre-election Statement [Month. De,. Wear, J~L ~ G ~ For Official use Only <br /> Supplemental Pre-election Statement (Attach a completed Form 495 to this statement.) <br /> Special Odd-Year Campaign Report <br /> Semi-annual Statement <br /> Termination Sieiement (Attach a comple~e~ Form 415 to this statement.) <br /> <br /> List any other <br /> Im lis Statement commwes not included in this consolidated statement that are controlled by you and any <br />  COmA/trees of which you have knowledge that are primarily formed to receive contributions <br /> or to make expenditures on behaff of ~,our candldao/. <br /> CoMMnTEE NAME <br /> I LO. NUMBER <br /> OFFICE S4)UG~ C)~ H~LD (adcLUO~ LOCATION AIM) DISTNCT NUMMR IF AlqlUCA~) <br /> <br /> RESIDENT ..... MAME OIr TREASURER CONTROLLED COMMITTEE? <br /> <br /> COMM~rEE MAME I.D. MUMSER <br /> COMMITTEE ADDRESS MO. AND STREET) <br /> <br /> __ ~ .. STATE_ ~CO0~ [] 'VSS I--I NO <br /> NAME OF TREASURER CowdnTEE M)DRESS (NO. AND STREET) <br /> <br />  MO. ANO STREET) CITY STATE m CQ~ AREA COOf. JDAYTIME PHONE <br /> CITY STATE Zlff CODE AREA COOf~AYTIME WE <br /> <br /> Attach 4dc~/on41 informadcMI on approprtate/y laM/ed cont/nuadon sheets. <br /> <br /> i <br />III verification <br /> I hive used all reasonable diligence in preparing this statement. I hive reviewed the statement and to the best of my knowledge the information contained herein and in the attached schedules is <br /> true and complete. I/.enLfy under penalty of.B~lury~ under the law, of the StatiJ4)f California that the foregoing is true and~)r.~ct. ./ J ,~_ ,~ <br /> ! <br /> Executed <br /> on~ At ~T TE By gGNATU~ Of TP~ASU~, <br /> DATE CITY AND ~ <br /> <br /> An offkeholder M candidate who controls a committee must also varify the campaign statament. I have used all reasonable diligence and to the best of my knowledge the treasurer has used all <br /> reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the in_.~a~dh con,~edJlere.~l,~J~he attached schedules is true and <br /> o, .rju ,. <br /> <br /> ' D~T~ CnY AND STATE SIGNATURE OF CANDIDATE;OFFICEHOLDER <br /> Executed on At By <br /> DATE CITy AND STATE SIGNATURE OF CANDIOATE/OFFICENOLDEP. <br /> <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE OF CANDIDATE/OFF~CEflOtDER <br /> <br /> FOR INFORMATION REQUIRED TO SE PAOVIDED TO YOU PURSUANT TO THE INFORMATION PRACTICES AC~ OF 1977. SEE !NFORMATK)N MA~AL 4~N CAMPAIGN DI$CLOSUR~ PROVISIONS OF THE POLITICAL REFOmd ACT <br /> <br /> <br />