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Officeholder, Candidate, Type or print in ink. COVER PAGE- LONG FORM <br /> Statement covers period Date Sta m p <br />and Controlled Committee <br />Campaign Statement - Long Form from <br />(Government Code Sections 84200-84216.5) <br />SEE INSTRUCTIONS ON REVERSE through <br /> of <br />Check one of the following boxes to indicate the type of statement being filed: Date of election if applicable: <br />B Pre-electionStatement (Month, Day, Year) ~ i Il For Official Use Only <br /> Supplemental Pre-election Statement (Attach a completed Form 495 to this statement.) <br />  S <br /> pecial Odd-Year Campaign Report <br /> Semi-annual Statement <br /> Termination Statement (Attach icom pleted Form 415 to this statement.) <br />I0 ~)fflceholder. Candidate, and Controlled Committee II Other Committees lot Incl ms =tat( ment: Unanyother <br /> Included in this Statement committees not induded in this consolidated statement that are controlled by you and any <br /> NAME~F OFFICEHOLDER OR CANDIDATE comm/ttees of which you have knowledge that are primarily formed to receive contributions <br /> /~,~/~~., ~a~//~_~ Or tO make expenditures on behaff of your candidacy. <br /> COMMITTEE NAME <br /> I <br /> OFFICE SOUGHT OR HELD (INCLUDE LOCATION AND DISTRICT NUMBER If APPLICABLE) I I.D. NUMBER <br /> RESIDENTIAL OR ~ NAME OF TREASURER cONTROLLED cOMMITTEE?[] YEs [] I~O <br />  ZIP CODE ~REA ('~?DE~DAYTIME PHONE COMMITTEE ADDRESS (NO. AND STREET) <br /> COMMITTEE NAME ' cn'Y STATE ZIP CODE AREA CODEJDAYTIME P~ONC <br /> <br /> I I.D. NUMBER <br /> I COMMIITEE ADDRESS / (NO. AND STREET) <br /> <br /> NAME OF TREASURER e cOMMn'tEE AOO~Ss (No. AN0 STREE~ <br /> <br /> PERMANEN1 ADDRESS OF TREASURER (NO. AND STREET) CITY STATE ZiP CODE AREA CODE/DAYTIME PHONE <br /> / <br /> CITY STATE ZIP CODE AREA ~DE//~YTIME PHONE <br /> /~'/~ (17/~'/. ~,~ ~~__. .~-, Attachadditionallnformatlononappropriatelylabeledcontinuatlonsheets. <br />I1'1 Verification <br /> I have used all reasonable diligence in preparin~ this statement. I have reviewed the statement and to the I~ of m~ knowledge the information contained herein and in the attached schedules <br /> true and ¢ompl,et~. [,f~,rti~ under pen&lty of I:~.._~jury under the ,a):~.~s of the Stat/~ of California that the foregoi,n.~e and correct. <br /> <br /> DATE CITY AND STATE ~// - ! SIGNATURE OF TREASURE~ <br /> An officeholder or candidate who controls a committee must also verify the campaign statement. I have used all reasonable d~jgence and to the bgs~of my knowledge the treasurer has used all <br /> reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the inf~9~con~eG/~er/ef~d in the attached schedules is true and <br /> <br /> F ~ATE CITY-A~ID Sf"ATE '~ ' ' ' SIGNATURE OF CANDIDATE/OFFICEHOlDER <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE O~ CANDIDATE/OfFICEHOlDER <br /> <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE OF CANDIDATE/OFFICEHOLDER <br /> <br /> fOR INFOIM~ATION RF~)IRED TO BE PROVIDED TO YOU PURSUANT TO THE INFOI~VIATION PILACTICES AL'-T OF 1977, SEE INFORMATION MAN~JAI. ON CAMPAIGN DlSCLOSUR[ PROVISIONS OF THE POLITICAl. REFORM ACtr <br /> <br /> <br />