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Recipient Committee <br /> Campaign Statement <br /> CoverPage <br /> (Government Code Sections 84200-84216.5) <br /> SEE INSTRUC710NS ON REVERSE <br /> Type or print in ink. <br /> Statement covers period <br /> from � <br /> �n�o�9n /a�3i�o / <br /> Type of Recipient Committee: nn comm�nees-comPie�e rares i,s,s,a�d a. <br /> � ONiceholder,Candidate Controlled Committee � Ballot Measure Committee <br /> Q State Candidate Election Committee <br /> Q Recall <br /> (AlsoCanpk(ePartSJ <br /> ❑ GeneralPurposeCommittee <br /> Q Sponsored <br /> Q SmallContributorCommittee <br /> Q Political Party/Central Committee <br /> 3. Committee Information <br /> Q Primarily Formed <br /> Q Controlled <br /> Q Sponsored <br /> �a�socomp�ereaertsl <br /> � PrimarilyFormedCandidate/ <br /> Ofliceholder Committee <br /> (ABOCanp�efePart]f <br /> I.D.NUMBER Q�n� <br /> -� <br /> L` ornm�i �}'e,e fa �l��..1' Qc�-rb�.v� /"��rr�e <br /> CTRFFT GIlf1PFCR /Nn P(1 FllV1 <br /> CITY STATE ZIP CODE AREA CODE/PHONE <br /> OPTIONAL: FAX/E-MAIL ADDRESS <br /> 4. Verification <br /> Date of election if applicable: <br /> (Month, Day, Year) <br /> 2. Type of Statement: <br /> ❑ Preelection Statement <br /> �Semi-annual Statement <br /> ❑ Termination Statement <br /> ❑ Amendment (Explain below) <br /> Treasurer(s) <br /> L , <br /> Oate Stamp <br /> �;,v <br /> COVER PAGE- <br /> Page� of <br /> ��y�f �} �� "j.._ For O�ficial Use Only <br /> ❑ Quartedy Statement <br /> ❑ Special Odd-Year Report <br /> ❑ Supplemental Preelection <br /> Statement-Attach Form 495 <br /> ZIP CODE AREA <br /> I have used all reasonable diligence in preparing and reviewing ihis statement and to the best of my knowledge the information contained herein and in the anached schedules is true and complete. I <br /> certity under penalry of perjury under the laws of ihe State of California that the foregoir� is true and correct., n � � „ <br /> Esacuted on � /3�% /d�7— <br /> Tp ¢o�a�e <br /> E:ecu�etl on � l �� �v� <br /> ��a <br /> Executed on <br /> By <br /> By <br /> By <br /> SignaW reof Canhdling Ol�iceliolder,Candtlate,State Mwsure Prqwnen� <br /> Executed on By <br /> Date � SgnalureMCanlydlingqlicehdder,CandCale,StaleMeasuraPropanent FPPCForm460(Jund01) <br /> FPPC Toll-Free Helpline:B6WASK-FPPC <br /> State of Gllfornia <br />