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SHORT FORM <br />Recipient Committee Type or Print in ink. Stat ~,~,;~,~ c.;;t.;;. F~ .~.~ Dale Siamp <br />Campaign Statement --Sho~ Form Irom <br /> <br /> Date ol Election F~ O{ficial Use O~y <br />c~orc~ble promises ~eiv~. <br /> <br />Check one of Ih. following boxes to indicate the type of statement being flied: (Month, Day, Year) <br /> <br /> ~ Semi-amual SlM~enl ~ Special Odd-year Campaign Re~ <br /> ~ ~pple~ntal Pm-elecli~ Statemml (At/a~ a mpleled Form 495 Io this sialem~t.) <br /> ~ Te~inalbn Slat~ent (Attach a c~plet~ ~rm 415 to Ihis slalemenL) <br /> <br />I Committee Information <br /> <br /> z <br /> <br /> ~m~E NUMBER -- <br /> <br /> III Verilicatlen <br /> ~is commitlee h~ nm received any con~butions, cumulative con~ibudons or miscell~eous <br /> this commit[~ h~ no[ ma~ or r~ived loans, ~d has no accm~ ex~n~s or ou~anding enforc~ble promi~s <br /> [ have u~d all re~nable d~igence in prep~ng ~is sm~ment. [ have review~ ~e sm~emem and m ~e ~t of my kno~dg~e info.aden con~n~ heroin is ~e and <br /> <br /> ~ CI~ AND STATE ..... ~G~T~E OF ln~En <br /> An officeholder, can~datc, or s~ m~surc pro~nent who consols a commi~l~ must also vegfy i~ c~i~ s~cmenL <br /> <br /> I hav~ u~d all rc~nabl~ dili~en~ ~d ~ ~c ~st of my knowledge ~ ~e~urcr ha u~ ~1 r~sonable diligcnc~ in prep~ng Ibis s~lemenL [ have r~viewed Ibc s~meni <br /> ~d lo thc ~st of my knowlcdg~ ~ info~agon con~n~ heroin <br /> foregoing is ~ ~d co~L <br /> <br /> Execuled on Al By <br /> Executed on Al By <br /> Execuled on Al <br /> <br /> <br />