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Officeholder, Candidate, Type or print in ink. COVER PAGE- LONG FORM <br /> a'nd Controlled Committee Statement covers period Date Stamp <br /> <br /> Campaign Statement -- LongForm from -3~ [~ Iff I~ <br /> (Government Code Sections 84200-84216.5) !~ i~;TM <br /> SEE INSTRUCTIONS ON REVERSE through ~p' :~.! J~*~ ~-. L~~ [~ <br /> ~ck o~ of t~ following ~xes to i~icate the ty~ of statement ~ing filed: Date of elation ff applicable: of <br /> ~ Pre~le~ionStatement (Month. Day. Year) OCT 5 19~ )r Official Use Only <br /> Supplemental Pre~le~ion Statement CA. ach a completed Form 495 tothis statement.) <br />  S~cial Odd-Year Cam~ign Re~ <br /> Semi-annualStatement ~/0~'~ ~/ /~ <br /> Termination Statement CA.ach a completed Form al S to this statement.) C;'7Y <br /> <br /> O~ceholder. Candidate, and Controlled Comm~ee Cement: <br /> Included in this Statement comm~ees not i~lu~d in this comolidated ~atement that ate controlled by you a~ any <br /> NAME OF ~EHOLDER OR ~A/E commf~ees of which you have knowle~e that ate pdma~i~ f~med to receive contri~l~ <br /> ~ ~/ ~ ~ ~ ~tomake ex.~.ureson~ffofyourca~. <br /> C~M~EE ~ME <br /> ~F~E ~ ~ ~ ~UDE i~T~ AND DISI~ NUMBER If A~L~ILE) ~ I I.D. NUMBER <br /> ~MDi~ai ~ IU~NEIt ADD. SS (~. AND / . ~ME M T~ASU~R C~TROLLED CMM~EE? <br /> <br /> STATE ~P C~i AEA C~BAYTIME ~i C~MBEE ADDRESS (NO. AND $T~) <br /> COMMI~EE NAME I i.D. NUMIER ~ STATE <br /> <br /> C~M~EE ~ME <br /> I C~M~EE ADD. SS (~. A~ ST~ET) I I.D. NUMBER <br /> I <br /> C~ STATE ZiP C~E A~A CO~AYTIME ~E ~ME ~ T~A~R C~TROLLED C~M~EE1 <br /> <br /> NAME OF TRE~URER / ) ' CIill iii ADD~S! (~. AND <br /> ~ANE~ ~$ ~ ST~ET) C~Y STATE ZIP CODE AREA C~AYTIME <br /> <br /> ~Y~ ~ STATE ZIP C~ A~A C~ESAYTIME ~E <br /> <br />Iii Verification <br /> I haul u~d III reachable diligl.(~ in preparing this statement. I have reviewed the statement and to the ~ of my knowledge the information contained herein and <br /> i true and complete. I ce~i~ ~nder ~nal~ of ~rju~ under the laws of the State of California that the foregoing il true and totted. ,/~ <br /> / DATE/ CITY AND STATE ~ / / $IGNATURE(~ TREASU~R <br /> An offtcehoMer ~ ~ldate who controls a comml~ee must also verify the campaign statement. I have used all reasonable diligence and to the ~st of my knowledge the treasurer has used all <br /> reasonable diligeKe in pre.ring this statement. I have reviewed the statement and to the ~ of my knowledge the information contained herein and in the a~ached schedules is true and <br /> complete. Ice~i~ under.naltyof.rju~ underthe lawtof the State of California that the foregoing istrue .~d torreS.Ex~uted on /O/~/q~ At ~~ ~tA~/ ~ By ~ ~ <br /> ~ DA~E ' AN SIGNATURE Of ~NDIDATE~Ff~E~DER <br /> Executed on At By <br /> DATE C~Y AND STATE SIGNATURE O~ ~NDIDATE~FF~E~DER <br /> Executed on At By <br /> DAlE CITY AND STATE SIGNATURE OF CANDIDATE~FFICE~DER <br /> ~OR INF~AT~ ~IREP TO BE PROVIDED TO YOU PURSUANT IO IHE IN~O~AT~N P~O~[S AO OF 1977, SEE IN~ORMA11ON MAN~AL ~N ~MPAIGN DISCLOSURE PROVISIONS O~ 1HE ~LITI~L REFORM ACT <br /> <br /> <br />