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OFFICEHOLDER AND CANDIDATE <br /> Officeholder and Candidate STATEMENT OF TERMINATION <br /> Statement of Termination DateStamp <br /> This form must be completed by officeholders and WHERE TO FILE: <br /> tocandidateSGovernmentthat Codeare eligiblesectiontO84214.terminate pursuant Officeholders and candidates must file1 <br /> Form 416 with the filing officer with <br /> whom they filed their original campaig <br /> Type or print in ink. statements (Form 470 or 490). L.~ <br /> I Officeholder or Candidate Termination II Office Sought <br /> NAME. OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELl :H YOU ARE FILING THIS STATEMENT <br /> <br /> RESIDENTIAL C~,~USINESS ADDRESS (~ -- NO. AND STRE ET <br /> JURISDICTION (IF APPLICABLE) I DISTRICT NUMBER (IF APPLICABLE) <br /> <br /> CITY [ STATE ZIP CODE <br /> ~,.S-C)/ _~ ~.~.~' ~ ~ ¢~ III Effective Date of Termination <br /> DATE FILING OBLIGATIONS WERE COMPLETED <br /> AREA CODE/DAYTIME PHONE NUMBER <br /> <br /> IV Verification <br /> <br /> For the of. lice 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 /> 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 /> D. I have eliminated or I declare that I have no intention or ability to discharge all debts, loans received, and other obligations; <br /> E. I have no surplus campaign funds; and <br /> F. I have 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 /> DATE CITY AND STATE SIGNATURE OF OFFICEHOLDER OR CANDIDATE <br /> <br /> FOR INFORMATION REQUIRED TO RE PROVIDED TO YOU PURSUANT TO THE INFORMATION PRACTICES ACT OF 1977, SEE INFORMATION MANUAL ON CAMPAIGN DISCLOSURE PROVISIONS OF THE POLITICAL REFORM ACT. <br /> <br /> State of California Fair Political Practices Commission <br /> <br /> <br />