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I <br />Officeholder, Candidate, Type or print in ink. COVER PAGE- LONG FORM <br />and Controlled Committee Statement covers period Date Stamp <br />Campaign Statement- Long Form from <br /> (Government Code Sections 84200-84216.5) <br /> SEE INSTRUCTIONS ON REVERSE through [~J:2~l!~-)~:~' J~ ~ ~ ~ ~ ~ ~ of_~ <br /> Check one of the following ~xes to indicate the ty~ of statement ~ing filed: Date of ele~ion B applicable: <br /> ~ Pre~le~ion Statement (Month. Day. Year) <br /> ~ Supplemental ere-ele~ion Statement (A~ach a completed Form 495 tothis statement.) ~~ I ~7 <br /> ~ S~cialOdd-Year Campaign <br />  Semi-annual Statement <br /> Termination Statement (A~ach a completed Form 415 to this statement.) <br />I, ~ffmceholder. Candmdate, and Controlled Committee tent: Ll~anyot~r <br /> Included in this Statement comm~ees not i~lu~d in this consolidated natement that are controlled by you a~any <br />  EOF OFFICEHOLDER OR ~NDIDATE commi~ees of which you have knowledge that are primarily formed to receive contrib~io~ <br /> O~ ~. ~~ ~tomake expe~itures on ~ha~ofyour ca.idaW. <br /> <br /> - C~M~EE ~ME II.D. NUMBER <br /> ~FICE SO~ OR HELD (INCLUDE L~T~N AND DISTRI~ NUMBER IF APPLI~BLE) <br /> I <br /> ~S~L~ BUSINE$~ ADD.SS t (NO. AND $T~E~ ~ME ~ T~ASURER CONTROLLED COMM~EE~ <br /> <br /> COMMI~EE NAME I LD. NUMBER ~ STATE ZIP CODE AREA COD~AYTIME <br /> I C~M~EE ADD.SS (NO. AND ST~ET) <br /> <br /> NAME OF TRE~URER ~ C~EE ~OO~SS lao. Rao <br /> PEiANE~ ADDJSS ~ TJASUJR (NO. AND STREET) C~Y STATE ZiP CODE AREA CODE~AYTIME P~E <br /> <br /> CffY STATE ZIP CODE l~l CODE~AYTIME <br /> A~ach a~iti~al inf~mation ~ appropriately la,led c~tinuation ~eU. <br />Iil Verification <br /> I h~ u~d ~ll r~mn~bl~ dili~n~ in pr~p~rin¢ thi~ ~t,t~m~nt. I h~ r~i~d th~ ~t~t~m~nt ,nd to th~ ~ o~ m~ kno~l~d~ th~ m{orm~tion {ont~in~d h~r~m ,nd in th~ ~rh~d <br /> , true and compl~. I ce~ify under ~n.l~ of ~y under the law~f the ~tate~f California that the forgoing is tru~nd~ corre~. ~ I~2~~ / <br /> ~ ~DATE - - <br /> cn~ A~ ST~t~ S~TU~ O~ ~ASU~ <br /> <br /> An officeho~er m ~ndidJte who controls ~ commi~ee must ~lso verify the c~mp~ign statement. I h~ve used ~11 re~son~ble~ce ~nd to the ~y ~wledge the treasurer b~s used ~11 <br /> re~son~ble diligence in preparing this statement. I h~ve reviewed the statement ~nd to the best of my knowledge the ~~nt~i~e~~J~ched schedules is true ~nd <br /> ~om p~,~,. ~ ,,~u~ ~,.~*~ o~ ~,iu~ u,~,~ ~,~ o~*~ S~,~ o~ C,,~or~, ~,t*h~ ~or,go~,g ~ ~,u~,~d~~/ <br /> <br /> cn~ AaOS~R t ~ S~aA~UeE OF ~amOA~omc~.~o~a <br /> E ~ecu~ed on At By <br /> o,~E cn~ Rao S~R~E S~aA~UeE O~ CRamOATE~OmCt~Ota <br /> <br /> Executed on At By <br /> <br /> ~oa ~aFOe~A~O~ RE~mEO ~O a~ eaowoto ~o ~ou eURSUAm ~0 mt ~a~o~*~oa e~CES A~ O~ ~. SEE ~aFoa~R~oa ~RaUAt Oa ~PR~Oa mSC~0S~eE eeows~oas OF T~E eo~m~ at~oa~ R~ <br /> <br /> <br />