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I <br /> <br />~.~fficeholder, Candidate/ ,ype o, print in ink. - LONG FORM <br />and Controlled Committee Statement covers period <br />Campaign Statement-- Long Form <br /> (Government Cbde Sections 84200-84216.5) <br /> JAN 2 8 <br /> SEE INSTRUCTIONS ON REVERSE l <br /> Check one of tho following bores to indicate the type of statement being filed: Date of election if applicable: <br /> B Pre-election Statement (Month, Day, Year) For Official Use Only <br /> Supplemental Pre-election Statement (Attach · completed Form 495 to this statement.) <br /> Special Odd-Year Campaign Report <br /> Semi-annual Statement <br /> Terminatmn Statement (Attach & completed From a 15 to this statement.) <br /> <br /> .~ment: Lmany <br /> Inclu~ lis Statement commmees ,,or ~luUed in tM conso,UateU .ate~m t~ a.e con,,~lee ~ you i.,e any <br /> I~E OF OFFICE HOLDER OR CANDIOATE corem/trees of whkh you h~ve knowledge that ere pHma[i/y formed eo rece/ve comribudom <br /> <br /> COMMITrEE ~AME <br /> I <br /> OFFICE SOUGHT De fiELD MICLUDf LOCATION AND DISTRICT NUMBER IF A~LICABLE) I I.D. <br /> I <br /> REMOENTIAL Ga ~USII~SS ADOI~SS ~ ~ / ~ NAME or TREASUreR CONTROtLED CO44MITTEE t <br /> C/TY STATE ~P COOl WA 4~OOFdOAYTIME I~ONE · COMMn'rEE ADDRESS (NO. AND STREET} <br /> <br /> COMMITTEE NAME I I.D. NUMeER CITY STATE ZI~ COOE AREA CODFJDAYTIME <br /> I COMMfTTEE ADD. SS (NO. AND STREET) [ I.D. NUMBER <br /> CITY STATE ZiP COO~ AREA COOfa:)AYTIME FflONE NAME M TREA~aJI~R COfdTI~MLED COMMrlTEE t <br /> NAME OF TREASURER COMW~E ~OMS$ MO. A~ ST~E~ ..,: <br /> I~l~ld~l~ MSS Of TREASUI~a ~NO. AND STREET) CITY STATE ~IP CODE Al~A COOrdDAYTlldi <br /> <br /> CITY STATE ~lP CODE A·EA COOfJDAYI'I~E PHONE <br /> <br />III Ve~ificaUon <br /> I hive used ell reasonable diligence in preparing this statement. I hive reviewed the statement ind to the best of my knowledge the information cont~rein end in the ittKhed schedules is <br /> pe ' under the la f the State o · ifornia that the foregoi?_~o_~.true end correct. ~ ~ <br /> E.ecut. on ' ^t <br /> ' / ISATE CITY AND SI~ATE SIGNATURE OF TREASUI~R <br /> <br /> An officeholder M candidate who controls a committee must also verify tho campaign statement. I have used all reasonable diligence ind to the best of my knowledge the treasurer has used <br /> reasonable diligence in preparing this statement. I hive reviewed the statement and to the best of my knowledge the information ccmtaio, ed Ilm;eij~&nd in the ittached schedules is true <br /> complete. ~erti~/~Jnder~en~ty~erJuryunde~the~ws~fthe~Stata~fC~if~rniathatthef~reg~ingistrue~dC~J~t~/ /// ~,'////~" <br /> <br /> TE CITY AM) STATE ' ' ' ~IG~IATURE OF CANDIDATE/Of FICEHOLD~R <br /> Executed on At By <br /> DATE CITY ANO STATE S~NATURE Of CANDIDATE/OFFICEHOI. DER <br /> Executed on At By <br /> DATE CITY AND STATE SIGNAFURE OF CANDIDATE/OfricEflOLDER <br /> <br /> fOR INFC)I~MATIOfll REQUI~P TO BE PROVIDED TO YOU PURSUANT TO THE INFORMATION PRACTICES ACT OF IS77, SEE INFORMATION MAN~AL 9N CAMPAIGN D~SCtOSUR! PROVtSION$ Of THE POLITICAL RE FORM ACT <br /> <br /> <br />