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Officeholder, Candidate, Typaor print in ink. COVER PAGE- LONG FORM <br />and Controlled Committee Statement covers period Date Stamp <br />Campaign Statement -- Long Form f,o. <br />(Government Code Sections 84200-84216.5) <br /> <br />SEE INSTRUCTIONS ON REVERSE <br />Check one of the foflowing boxes to indicate the type of statement being filed: Date of election if I For Official Use Only <br /> Pre-election Statement (Month. Day. Year) i ~N 3 0 <br /> Supplemental PrHleCUOfl Statement (Attach a completed Form 495 to this statement.) i : <br /> Special Odd-Year Campaign Report <br /> Semi-annual Statement ~ CiTY ~ <br /> Termination Statement (Attach a completed Form 4! S to this statement.) <br /> L~ ~ny nthor <br /> Statement co~mw,, not/nc/udedin th/s con~//dated statement ~haf are controfled by you and <br /> In( <br /> lis <br /> NAME OF OFFICEHOLDER OR CANI~DATE coma/flees of wh/ch you have k~ that ere pr/mad/y formed to race/ye contr/budom <br /> ~ ortomek..#pendituresonbehMfof~,ourc, ndidec~. <br /> COIdMITTEE NAM~ I.D. NUldIER <br /> ~~ ,~ NAME O~ TREASURER CONTRGL~D COMMITTEE1 <br /> <br /> CITY STATE ~COOf ~--',ld~ CI~f~YI~ FflQ44 CO~EE AD--SS (NO. AJiO STI~ET) <br /> <br /> ~ or TREASUI~R CONTROLLED COMIdflTEE t <br /> ~ A STA. Z~P CODE A~A ~YTIME Pfl4~E __ <br /> ~~l ~ ~~ / /dl~ ~4 /"~/ ~"~ ~" -- COMMITTEE ADDMSS MD. AND STMST) <br /> <br /> flMAAIMNT MSS O/TREASUI~R · CITY STATE Zle COM AW COOF. A)AYTIME PHONE <br /> CITY STATE ZIP CQIX ARE& COMJDAYTIME PflON~ <br /> <br />III Verification ' <br /> I hive used iii reasonable diligence in preparing this statement. I have reviewed the statement and to,the be~t. of. m~v~d. J~t.he in/f~miJ~)~/e6f~~ein end in the attached Khedulm is <br /> true and complete. ~c~rt~fyund~rpan~ty~f~e~rjury~nd~rthelews~ftheS-tat~fC~iforni~thattheTOFe~orng~14:r~mm.~(:~rect:///%~/// / ~'~-'~, <br /> Executed on /~'~) "~' ' At ~/7'~ ~: ~-/-~~ ~/ C~r- By /~'~/~,"a/'~'t"~ff/'~ ~"~/' ' <br /> DATE CIty AND STATE SIGIMTUM OF TPJ'ASUMR <br /> <br /> An officeholder or candidate who coMrols I committee must elM) verify the campaign statement. I have used ell reasonable diligence and to the best of my knowledge the treasurer has used all <br /> reasonable diligence in preparing this statement. ! have reviewed the statement and to the best of my knowledge the informltion contained herein and in the attached Khedules is true ~nd <br /> complete. I certify under penalty of perjury u~ndgr the laws of the State ,of California that the foregoing is true and/eprrect. <br /> / <br /> 4~ / CITY AND STATE ~ ./ SIGNATURE OF CAND4DATEIOFFICEHOLDEI <br /> Executed <br /> on <br /> DATE <br /> Executed on. At By <br /> DATE CITY AND STATE SIGNATURE OF CANDIDATE/OFFICEHOLDER <br /> <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE OF CANDIDATUOFFICEHOLOFR <br /> <br /> FOR INFORMATION I~QUlI~D TO BE PROVIDED TO YOU PURSUAN1 TO THE INFORMATION PRACTICES AC1 Of 1177, SEE tNFORMAT~N MANUAL ON CAMPAIGN DISCLOSURE PRQVlSK)~$ OF THI~ POLII~A~. REFW A~... <br /> <br /> <br />