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COVER PAGE - LON~ FO~M <br />0~ficeholder,Candidate, ~ype m print in ink. Statement (over, ~,i~ I Date 5tamp <br />and Controlled Committee <br />Campaign Statement.-- Long Form ~,o= -~1~ t.t I~cl,~ _ ~ ~ ~,~ r? , <br />{GovemmentC~eSe~ions.4200-042'6.5) ,h,ough ~¢F' 7~t ' G~ ~~g [~1 ~ <br />SEE INSTRUCTIONS ON REVERSE <br />~c~ one of the following ~es to indicate the type of statement ~lng filed: <br /> Pre.le~ionStatement (Month. Day, Ye.,) :~;~[~ ~ 7 '~ <br /> ~ 5upplemental Pre_ele~ion Statement (A~ach a completed Form 495 to this statement-) /~"['~ 5~~ ~ T ~ ' <br /> S~cialOdd-YearCampaignRe~ ~O~', ~ , / [ ~ ~ oV( ~0WO0?CiTY <br /> Semi-annual Statement ;, ~ /~' ~_~ <br /> Termination Statement CA.ach a completed Form 415 to this statement.) <br />I' Officeholder. Candidate, an Controlled Committee II Other Committees-Not Included in this Statement: <br />Included in this Statement commlUee~ no~ i~lu~d in ~hls consolidated ~a~emen~ lha~ are con~rolled by you <br /> ~omml~ee~ of which you have knowle~e thai are prlma~lly fo~med ~o ~eceive <br />NAME OF ~EHOLDER OR ~NDIDRIE or ~o make expe~i~ures on ~ha~ofyour <br /> <br /> ~l~E ~ ~ HE~ 0~UOE L~i~ AND DIST~ NUMIER IF APPLI~ILE) <br /> ~$1DE~L OR IUM~[$S ADD~$S (~. AND ST~E~ / -- ~ME ~ T~AIU~R CONIROLLED C~M~EE1 <br /> C~Y ~fAl[ ZI~ COO[ AEA (OO[~AYII~[ ~ON[ CO~MB[[ ADDRE55 ~NO. AND <br /> COMMI~EE NAME I I.~. NUMIER ~ STAll ZIP COO[ AEA [OOBAflI~[ <br /> <br /> C~M~EE ADD.SS (NO. ANb STREET) <br /> C~Y STATE ZIP C~E AEA CODE~AYTIME PHil ~ME ~ T~ASU~R C~TROLLED <br /> <br /> NAME OF TRE~URER . f <br /> <br /> C~Y lille ZIP CODE AREA CODBAYTIM[ <br /> PE~AN[~ ~D~S& ~ T~ASU~R ~NO. AND ST~ET} <br /> <br /> C~Y STATE ZIP CODE A~A CODE~AY11ME ~E <br /> <br />III verification <br /> I have u~ed all ~ea~nable diligence in preparing thi~ ~tatement. I have reviewed th~ statement and to the ~ of my knowledge the into[matRon (ontain~d herein and in the a~a(hed ~(hedule~ <br /> t~ue and complete. I [e~ify under ~nal~ ot ~[ju~ unde~ the law~ of the 5tate of California that the foregoing i$ true and (or[e~. ~.~'-) <br /> <br /> ' / DATE/ CITY AND ITAIE / / ~ SlGNATUR[~OI TREASU~R <br /> <br /> An officeholder m ~ndldate 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 diligence in pre.ring this statement. I have reviewed the statement and to the be~ of my knowledge the information contained herein and in the a~ached schedules is true and <br /> <br /> E~ecuted on ' DA~E ' C~Y AND STALE / t ' SIGNATURE el ~NDIDATE~KEH~DER <br /> Executed on At By <br /> DAlE C~Y AND STALE 51GNAIURE OF ~NDIDA[E~FFICE~DER <br /> <br /> By <br /> Executed on At <br /> DAlE CIIY AND SIAIE SIGNAIURE Of CANDIDAIE/O~FICEH~DE R <br /> <br /> ~OR IN~ffiMATIO4 RE~IRE~ IO IE PROVIDED IO YOU PURSUANI IO 1HE INIO~AIlON P~ICES A~ O~ 1~77, ~EE INFORMAilON MAN~RL ON ~MPAIGN DISCLOSURE PROVISIONS OF IH[ POLIII~L REFORM ACI <br /> <br /> <br />