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! <br />Officeholder, Candidate, Type or print in ink. cOVER PAGE'- LONG FORM <br />and Controlled Committee Statement covers period Date Stamp <br />Campaign Statement -- Long Form <br />(Government Code Sections 84200-84216.5) <br />SEE INSTRUCTIONS ON REVERSE through <br /> Check one of the following boxes to indicate the type of statement being filed: Date of election if a Page of <br /> [] Pre-election Statement (Month, Da JUL ~ 6 ~ 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 Statement (Attach ~ completed Form al 5 to this statement.) <br /> <br /> List any other <br /> Included in lis Statement committees nOt included in this consolidated statement that are controlled by you and any <br /> NAME OF OFFICEHOLDER OR CANDIDATE camm/trees of which you have knowledge that are primarily formed to receive contributions <br /> dUD~ ~ ' or to make expenditures on behalf of your candidacy. <br /> COMMITFEE NAME I I.D. NUMBER <br /> OFFICE-SOUGH~ OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER IF APPLICABLE) <br /> <br /> RESIDENTIAL OR BUSINESS ADDRESS (NO. AND STREET) NAME Of TREASURER CONTROLLED COMMrlTEEt <br /> OYES ONo <br /> CITY STATE ZIP CODE AREA CODE/DAYTIME PHONE COMMITTEE ADDRESS (NO. AND STREET) <br /> <br /> COMMITTEE NAME .... I I'D'~"NUMRER CITY STATE ZIPCODE AREA CODF./DAYTIME PHONE <br /> I <br /> <br /> I COMMITTEE ADDRESS (NO. AND STREET) <br /> <br /> ~L~ME OF TREASURER COMMITTEE ADORESS (NO. AND STREET) <br /> PERMANENT ADDRESS O~r TREASURER (NO. AND STREET) CITY STATE ZIP CODE AREA CODE/DAYTIME PHONE <br /> <br /> CITY STATE ZIP CODE AREA CODE/DAYTIME PHONE <br /> Attach additional information on appropriately labeled continuation sheets. <br /> <br />III Verification ' _ ,~ _ , <br /> <br /> true and cam plete. [ certifl under penalty of]~rjury under the laws~f the State,~f California that the foregoing is <br /> Executedon "~!~1~ ' At "~e~Ue~ ~.'~ ~:~:. By <br /> ' D~,T~ ' CiTY AND STATE' ' - ' - ' SIGNATURE Of TR(ASURER <br /> <br /> An officeholder or candidate who controls a committee must also verify the campaign statement. 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 information contained herein and in the attached schedules is true and <br /> complete. I certify ~/nderjI)enalty of perjuryExecuted on ~'~/fr~1~' , . At ~a~l~ ~[ ~e laws of the StatciTy AND STATEf Cal'fo~~egoing is true ,nd/~rrect., By [/~'/~/" /~J~L~L I~''~/'~ <br /> SIGNATURE <br /> OF <br /> CANDIDA <br /> TE/OFFICEHOLDER <br /> L/ <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE OF CANDIDATE/OFFICEHOI. DER <br /> <br /> Executed on At By <br /> DATE CITY AND STATE SIGNAIURE OF CANDIDATE/OFFICEHOLDER <br /> <br /> FOR INFORMATION RE(~UIRED TO BE PROVIDED TO YOU PURSUANT TO THE INFORMATION PRACTICES AC3 OF 1977, SEE INFORMATION MANUAL ON CAMPAIGN DISCLOSURE PROVISIONS OF THE POLITICAL REFORM ACT, <br /> <br /> <br />