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Officeholder and Candidate T¥~. m' print in ink. SHORT FORM <br />Campaign Statement -- Short Form DateStamp <br /> <br /> For Official Use Only <br />For use by officeholders and candidates who do not have a controlled committee and who do not anticipate JUL J 8 J996 <br />receiving $1,000 or more in contributions and do not anhcipate spending $1,000 or more during the <br />calendar year. Officeholders whose salary/is less than $100 per month and judges who have a controlled <br />committee may use this form under certain circumstances See the Information Manual on Campaiqn <br />Disclosure' Provisions of the Political Reform Act for Elected Officeh~-i-d~, Candidates, and Their Controlled ~i'i¥ OF CITY <br />~.ommittees ol'-~Tur~ information. <br /> <br />I Statement Covers Calendar Year 19 ~ . <br />II Officeholder or Candidate Information III Information on Office Sought or Held <br /> NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD <br /> <br /> RESIDENTIAL OR BUSINESS ADDRESS (NO AND STREET_,~, <br /> ELECTION (MONTH, DAY. YEAR) (IF E) <br /> <br /> AREA CODE/DAYTIME PHONE NUMBER <br /> <br />IV Committee Information <br /> List all committees of which you have knowledge that are primarily formed to receive contributions or to make expenditures on behalf of your candidacy. <br /> <br /> COMMITT~[ NAM[~ AND I p NUMBER (;0MMtTTI~I~ AppRE~ NAME Q~ TREASURER <br /> <br />V Verification <br /> I declare under penalty of perjury that to the best of m~ knowledge, I anticipate that I will receive less than $1,000 and that I will spend less tilan $1,000 during <br /> the <br /> <br /> <br /> <br /> IO~ P~C[I(E5 ~(l OF 19~ ~ E INFORMATION MANUAl ON CAMPAIGN DISCLOSURE PROVI~ION~ OF T~E ~LITI~L REFORM <br /> <br /> State of California Fair Pollti(al Pra(tkes (ommh~lon <br /> <br /> <br />