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Officeholder and Candidate Type or print in ink. SHORT FORM <br /> Campaign Statement -- Short Form DateStamp <br /> (Government Code Section 84206) <br /> <br /> For use by officeholders and candidates who do not have a controlled committee and who do not anticipate <br /> receiving $1,000 or more in contributions and do not anticipate spending $1,000 or more during the <br /> calendar year. Officeholders whose salary is less than $100 per month and judges who have a controlled <br /> committee may use this form under certain circumstances. See the Information Manual on Campaiqn <br /> Disclosure Provisions of the Political Reform Act for Elected OfficehOlders, Candidates, and Their Controlled <br /> ~:ommittees o~0~T0-/~r information. <br /> <br /> I Statement Covers Calendar Year 19 <br /> II Officeholder or Candidate Information III Information on Office Sought or Held '---' <br /> <br /> 6ESIDENTI~L OR BUSINESS ADDRESS (NO AND STREET) JURISDICTION (LOCATION) <br />  DISTRI~ NUMBER <br /> CITY SlA] E ZIP COD~ DAlE OF ELECTION (MO~TH. DAY. YEAR) (IF APPOCABLE) <br /> AR~A ~OD~IDAYTIM~ PHONE <br /> <br />IV Committee Information -'~ --- .__... <br /> List all committees of which you have knowledge that are primarily formed to receive contributions or to make expenditures on behalf of your candidacy. <br /> <br /> COMMITTEE NAM[ AND I D I~UMBER (~QMMITTEE ADDRI~; NAME OF TREASURER <br /> <br />V Verification '------ <br /> I declare under penalty of perjury that to the best of my. knowledge, I anticipate that I will receive less than $1,000 and that I will spend less t~an $1,000 during <br /> the calendar year and that I have used all reasonable diligence in preparing this statement. I certify under penalty of perju~ry under the laws of the State of <br /> California that the foregoing is true and correct. <br /> <br /> Executed on At. By ,, , <br /> DATE CITY AND STATE SIGNATURE OF OFFICEHOLDER OR CANDIDATE <br /> <br /> fOR INfORMAIIDN R[OIIlfl[ L) [O BE PROVIDED TO YOU PURSUANI IO life INFORMATION PRACTICES ACT DE 1972, SEE INFORMATION MANUAl. ON CAMPAIGN DISCLOSURE PROVISIONS OF FHE POLII'ICAL REFO_~RRM AC] <br /> <br /> State of California Fair Political Practices Commission <br /> <br /> <br />