La Berge 01-01-1996 thru 12-31-1996 470

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Officeholder and Candidate T¥.e o, print in Ink. SHORT FORM Campaign Statement -- Short Form DateStam. Fo~ use by officeholders and candidates who do not have a controlled committee and who do not anticipate receiving $1,000 or more in contributions and do not anticipate spendin9 $1,000 or more during the calendar year Officeholders whose salar~ is less than $100 per month and judges who have a controlled committee may use this form under certa.~ circumstances. See the Information Manual on Campaiqn Disclosure Provisions of the Political Reform Act for Elected Officeholders, Candidates, a~d Their Controlled ~ommittees I Statement Covers Calendar Year 19 II Officeholder or Candidate Information III Information on Office Sought or Held NA~ OF OFFICEtlOLDER O~ CANDIDATE OFFICE SOUGHT OR HELD RESIDENTI~R BUSINESS ADDRESS~ (NO AND STREET) JU [ISDICTION (LOC ~ON) ~ ~ J DISTRI~ NUMBER (if APPLICABLE) I ( IT Y S 1 AREACODE/DAYTIM[ PHONE N~MBER IV Committee Information List all committees of which you have knowledge that are prJmardy formed to receive contributions or to make expenditures on behalf of your candidacy. COMM~1T~ NAME AND I D ~JM~E~ .... ~QMMt~T[~ A~pRE~ NAME ~ TREASURER V Verification I declare under penalty of perjury that to the best of my. knowledge, I anticipate that I will receive less than $1,000 and that I will spend less titan $1,000 during the calendar year and that I have used all reasonable ddigence in preparing this statement. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. l OR INfORMA 1 ION fl[ QHIRI D IO 8[ PROVIDED TO YOU PURSUANI IO 1 It[ INFORMAIION p~CTI([S ACI Of 1917, SE [ INFORMAIION MANUAl ON CAMPAIGN DISCtOSUR[ PROVISION~ Of THE ~LIII~L REFORM State of California Fair Political Pta(ti(es Commission