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CIT3' CLERK DEPARTHENT i ()N(; I:()1~1~1 ' <br />Officeholder, Candidate, typ.or Print in Ink. Fstat®m,,' covo~"Pa,iod . <br />and Controlled Committee <br /> / <br />Campaign Statement -- Long Form I"-- <br />(Govc~enl ~ S~U~s 842~-842165) <br />SEE I~TRUCTIONSONRE~R~ I ,hm~h ~/~/~ ~ Z3 ~ <br /> <br /> C~mk o~ el ~ followl~ ~aee Io i~male I~ I~ ~1 etat~nl ~1~ ~le~ Dala of Elegtio~ A F~ Olhc~al Use Only <br /> <br /> ~ Pm-elecl~ ~al~l il ap~icable: <br /> ~ ~pp~nlM Pre-el~l~ Slale~l (Alla~ a ~pleled F~m 495 Io Ibis slale~l ) Igonl~ Oay, <br /> ~ ~mi-a~ual Slal~enl <br /> ~ Termmal~ Slalmnl (~lach a c~p~ ~rm 415 Io Ibis slalmnl ) <br /> <br />I Oflice~lar~ Can~le~ II Olher Callee~ Nol I~luded in <br />a~ Controlled Co~ttee c~mees ~t i~l~ed m t~ c~olMmed state=m <br />IncIMed in Ibis $1aleanl c~btee~ of w~ch ~u ~ ~ledge t~t ~e pri~ily f~d to receive c~ributiom or <br /> <br /> ~f~ ~ ~ ~ (~ L~AT~ ~ ~Sl~l ~R ~ ~ E ) <br /> ~EE ~: I I O ~R CITY STALE <br /> <br /> ~ ¢ T~R: C~REE ~: (~ ~ST~) <br /> <br />IN Verification ~ll~hol~r m ~ndMate: <br />Tr~: l ~vc u~ aU ~lc d~iKc~ ~ m ~ <br />i ~ ~ ali r~blc diliKc~ in ~nK ~is s~K~m ~ m ~ ~ of my u~d MI r~ dilis~ b pc~in~ ~is <br />k~w~c ~ b(~i~ ~i~d ~cin ~ in ~ ~ ~u~ is ~ and ~nl ~ m ~ ~. ~ my k~wlcdgc ~ in(~i~ ~mi~ herein <br /> <br /> ~ ~F~II~ REf~IIRED lOBE ~OVID[D IO Y~ R~ISUANI 10 ltl[ I~MAI~ PRACI~ES ACI OF 191/. ~E I~~~ ~PAIG~I OISC[O~RE ~O~S <br /> lille el Calilor~a Fair Political Practice8 Commission, <br /> <br /> <br />