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COVER PAGE -- LONG FORM <br />Recipient Committee Type or Print In Ink. Statement covers period DaleSLa~0 ...... ~F. lnlli~t~l~,d I~k]rl __ <br />Campaign Statement--LongForm ' ,~m ~, / ~~~ <br /> C~k e~ off the followl~ ~xel Io I~clle I~ ly~ el stalemnl bel~ Illet Date el Elecllo. A F~ Olfic~l Use ~y <br />~ Pre-el~t~fl State~ ~ Se~-~nual Slal~e~ II applicable= ~ <br />~ Special ~d-yea[ C~aigfl RG~ IMonl~ Day, Year) <br /> CI~ CLE '~. <br />~ ~p~ntal Pie-elation Stat~ {A~ach 8 c~leled Fo~m 495 lo this state~nl.) ~ <br />~ Tef~n~ion Slate~nt {ARach 8 c~81ed F~m 415 Io this slate~nl.) <br /> <br /> I Committee Information II Prirnadly Formed Committee (See definition on reverse.) <br /> List names of officeholder(s) or candidate(s) for which this <br /> .*U~O~C.O~TTE~: committee is primarily farmed <br /> (C~ck Bo~s) $** ~finitio~ ~ ~rl~t ~tion on r*~rse. <br /> I$ ~is. a~n~ commits? .................................... ~ Yes ~ No <br /> ls~iaeN~li~l~mit~ ................... ~ ~ea ~ No <br /> III Verification <br /> I ~vc u~ all rc~blc diligc~ in p~c~ng ~is s~mcnt ~d to thc ~st of m~ k~wl~ge ~ inf~at~n ~mi~ h~cin and in ~e at~h~ sch~ul~ is ~ and <br /> E~u~ ~ ~. <br /> <br /> <br />