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~ I RECIPIENT COMMITTEt <br /> Recipient Committee WHERE TO FILE: STATEMENT OF TERMINAT QN <br /> Date Stamp <br />Statement of Termination File originaland one copyofthis form with:RECi IVED ~' ~." <br /> .,-, ,~ L, FiLEO <br />This form must be completed by recipient committees Secretary of State I/1 Jhe l ~l~'~a 0~ ~!'i~ ~r,~ n~, $ ~:*a, <br /> Political Reform Division ~ , ~, ~ . <br />that are eligible to terminate pursuant to Government P.o. Box 1467 ~h~ ~ ~ g ~ b~ 0 fi 8 For Officml U~ Only <br />C~eSe~ion84214. Sacramento,~95812-1467 ~ 0 ~ 1~ <br /> Ty~ or print in ink. A~, ~ applicable, fi~ o~ copy of this form w~ <br /> The cry or coun~ officer, if any. who recei~s t~aN~ ~eue~ al 81ale <br /> commi~ee's campaign di~l~ure ~atemen~. ~ <br /> I Recipient Committee lnformation II Treasurerlnformation <br /> . NAME OF COMMITTEE LO. NUMBER NAME OF TREASURER ~ <br /> C~l~ ~ ~LEC~ ~O~ ~JS~ ~P/7~ MAIUNGADDRESSOFTREA5URER NO. ANDSTREET <br /> AOO~ESS OF COmmiTTEE NO. ANO STREET ~/~ ~ ~ ~ <br /> STATE Z,eCO0 <br /> CITk~ STATE ZIPCODE ~ ~ ~ ~ C /. y ~ , ~ ~ ~ <br /> ~ 0 C/=/ C~ ~ ~ AREACODE~AYTIME PHONE NUMBER <br /> AREACODE~AYTIMEPHONENUeBER ~ ~/S-) 3: ~-- q~a <br /> (~/~) ~ ~- q ~v 0 III Effective Date of Termination <br /> DATE FILING OBLI~TIONS WERE COMPLETED <br /> <br />IV Verification <br /> A. This committee has ceased to receive contributions and make expenditures; <br /> <br /> B. This committee does not~nticipate receiving contributions or making expenditures in the future; <br /> <br /> C. This committee has eliminated or ~leclares that it has no!ntention or ability to discharge all debts, loans received, and other obligations; <br /> D. This committee has no surplus funds; and <br /> <br /> E. This committee has filed all campaign statements required by the Political Reform Act disclosing all reportable transactions. <br /> <br /> I have used all reasonable diligence in preparing this statement, i have reviewed the statement and to the best of my knowledge the information contained <br /> herein is true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. <br /> <br /> Executed on At By <br /> E~ecuted on At By <br /> <br /> State of Calitornia Fal~ Political P~actices Commission <br /> <br /> <br />