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LONG FORM <br />Officeholder, Candidate, Type or Print In Ink. Statement covers period Dalo Stamp <br />and Controlled Committee <br />Campaign Statement-- Long Form from ! ~ i ~ c~ ~ <br />(Govcmmem Code Scccons 84200-M216.5) <br /> <br /> Check one of the following boxes to indicate the type of statement being filed: Date o! Election : ~ A Fo~ Ollicial Use Only <br /> [] Pre-election Stalemefl, il applicable: JAN 2 0 ~ <br /> [] Supplemental Pre-eleclioR Statement (Attach a compleled Form 495 to this statement.) (Month, Day, Year) <br /> .~Sumi-annual Statement ~/i~r CITY CI.ERK <br /> Terminalion Slatement (Atlach a completed Form 415 to Ibis $1atemenl.) <br /> <br />I Officeholder, Candidate, II Other Committees Not Included in this Statement: List any other <br />and Controlled Committee committees not included in this consolidated statement that are control/ed by you and any <br />Included in this Statement committees of which you have knowledge that are primarily formed to receive contributions or <br />/.~.. ~: OFF~'~HOL~R OR C~TE: to make e~penditures on behalf o/your candidacy. <br /> <br /> OFFICE SOUGHT OR HELD: (IHCLU(~ LOCATION AND DI~IRICT NUMBER IE APPtlC. ABLE) / . <br /> <br /> REStDENTIN,_ O~ eOSINESS kOi~ESS: (140 ~ SIREEI} ' NAME OF TSEASURE8: CON ? <br /> CITY STATE ZIP CODE AREA CO~EJOAYTIME PHONE COMMITTEE ADOflESS: (NO AND SIREET) <br /> COMMITTEE NAME: I O NU~fl CITY STATE ZIP COOE AREA CODFJDAYTIME PHONE <br /> <br /> COIdMII~EE ALX]nEss: (NO. ~ STREET) I <br /> I <br /> CITY STATE ZIP COO~ AREA CO(~:JC~YTIME PHONE NAME OF TREASURER: CONTROLLED COMMtTIEE? <br /> <br /> - : ' ' COMMfEIEE A~ESS: (NO. ~ STREET ) <br /> <br /> PERMANENT ADI~flESS OF TREASURER: (NO. ANO S'i~EET) CIIY SIATE ZiP COO~ AREA CO[]F-~[~AYTIUE PHONE <br /> <br /> '¢¢'.')vz)fOo U r'-/--.-- p.rt. q' TC//, . <br /> <br />Iii Verification Officeholder or Candidate: <br />Treasurer: I have used all reasonable diligence and to (he bcsl of m? knowledge Ibc treasurer has <br />I have uscd all reasonable diligence in @rcparing Ibis slarcmcnl and to Ihc bcs( o~ my uscd all rcasonablc diligence in prcpa~ing Ihis slalcmcm. ! have reviewed thc <br />knowlcd§c Iitc information conlalncd hcrcin and in Ibc auachcd schedules is linc and mcm and ~o (he hcst of my knowlcd§c Ibc infon~adon conlaincd herein and in Ihc <br />complclc. ! ccrdfy under pcnal~y of perjury under Ibc laws of Ibc Smtc of California almchcd schcdulcs is uuc and complclc. I ccndy under pcnal~y of perjury under Ibc <br />Ilml thc foregoing is mm and corrccL laws o[ Ibc Sla~c of California ihs( thc [oa~oin;is uuc and corrcct. <br /> <br /> ,. ; - .,,,,: - - -o,,,,,,,,,.,,,,,,: ( ,..-... c,,¥,,,,,,s,,,,, , <br /> <br /> // ...... ~' E~FTR ~ER -- SIGNATURE OF OFFICEHOLDER OR CANDIOATE ~ <br /> FOR IHFCSIq~TIOt4 REOLJIRED TO BE PR©¥1DED TO Y~U PURSUANT TO THE INFORMATION PRACTICES AC T OF 1977. SEE INForMATION MANUAL ~ CAMPAIGN DISCLOSURE PRO¥1SIOHS (~F THE PQLI~JC~L REFORM <br /> $1ale ol California fait Polilical Practices Commission. <br /> <br /> <br />