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OFFICEHOLDER AND CANDIDATE <br /> STATEMENT OF TERMINATION <br />Officeholder and Candidate ,--t, <br />Statement of Termination WHERET FILE <br />This form must be completed by officeholders and 0 : J ........... <br />candidates that are eligible to terminate pursuant Officeholders and candidates must file <br /> For <br /> Official <br /> Use <br /> Only <br /> <br />tO Government Code Section 84214. Form 416 with the filing officer with <br /> whom they filed their original campaig( <br /> / <br /> Ty~ ~ ~int in Ink. statements (Form 470 or 490) <br /> ' <br /> ~,-I. CI]YCLERK J j <br />I Officeholder or Candidate Termination II Office Sought or Held <br /> NAME OF OFF~EHOLDER OR ~NDID~E -- J OFFICE SOUGHT OR HE~ FOR WHICH YOU ARE FILING THIS STATEMENT <br /> <br /> JURISDICTION (1[ APPLICABLE) DISTRICT NUMBER (If APPLICABLE) <br /> RESIDENTIAL OR BUSINESS ADDRESS ~. ~D STREET <br /> <br /> CITY $TATE Z~PCOD[ III Effective Date of Termination <br /> <br />IV Verification ' <br /> For the office listed in Part II of this form, I verify that: <br /> <br /> A. I do not hold or am no longer a candidate for the office; <br /> <br /> B. I have ceased to receive contributions and make expenditures; <br /> C. I do not anticipate receiving contributions or making expenditures in the future; <br /> <br /> D. i have eliminated or I declare that i have no intention or ability to discharge ail debts, loans received, and other obligations; <br /> E. I have no surplus campaign funds; and <br /> F. I have flied ali 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 /> Executedon /.,~/~' Al' ~e~---,~ By ~/~'~4"aL~/~'~?~ <br /> DATE ' CiTY AND $1AIE J SlGNAIURE OF OFIclCEHOLDER OR CANDIDATE <br /> <br /> FOR INFORMATION R[()UII~D 10 J[ PROVIDED TO YOU PURSUAN1 TO THE INFORMATION PRACI'ICES ACJ Of 1977, SJJ INFORMATION MAN~JAI~ ~)N CAMPAIGN DISCLOS~JRE PROVISIONS OF THE POLITICAL REFORM <br /> <br /> State of California Fair Political Practices Commission <br /> <br /> <br />