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RECIPIENT COMMITTEE <br /> - ''Recipient Committee WHERE TO FILE: ~ <br /> STATEMENT <br /> OF <br /> TERMINATION <br /> Date Stamp <br /> Statement of Termination File original and one copy of this form with: <br /> Secretary of State <br />This form must be completed by recipient committees Political Reform Division <br />that are eligible to terminate pursuant to Government P.O. Box 1467 For Official U~e Only <br />Code Section 84214. Sacramento, CA 95812-1467 <br /> <br /> Type or print in ink, And, if applicable, file one copy of this form with: <br /> The city or county officer, if any, who receives the <br /> committee's campaign disclosure statements. <br /> <br />I Recipient Committee Information II Treasurerlnformation <br /> NAME OF COMMITTEE I.D. NUMBER NAME OF TREASURER <br /> ~(V'~'~I (~ '~) ~~ ~)~~i ~'~" (~C~ 1~'~ ~)~ MAILING ADDRESS OF TREASURER NO. ANDSTREET ' <br /> ADDRESS OF COMMITTEE NO. AND STREET <br /> :~ ~/ ~(~' ~,~. '~f~C'v't~Y [ ~,,. CITY STATE ZIPCODE <br /> <br /> CITY STATE ZIP CODE <br /> <br /> i,~ (~ii~, ¥,~ OS ~.~-~ ' lit/(i..~'.~t ~ AREA CODE/DAYTIME PHONE NUMBER <br /> <br /> AREA CODE/DAYTIME PHONE NUMBER <br /> ~ III Effective Date of Termination <br /> DATE FILING OBLIGATIONS WERE COMPLETED <br /> <br />IV Verification <br /> A. This committee has ceased to receive contributions and make expenditures; <br /> <br /> B. This committee does not anticipate receiving contributions or making expenditures in the future; <br /> <br /> C. This committee has eliminated or declares that it has no intention or ability to discharge all debts, loans received, and other obligations; <br /> <br /> D. This committee has no surplus funds; and <br /> <br /> E. This committee has filed all campaign statements required by the Political Reform Act disclosing all reportable transactions. <br /> <br /> I have used all reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the information contained <br /> herein is true and complete. I certify under pen~of perjury under the laws of the State of California that the foregoing is true and correct. <br /> <br /> Executed on , At By <br /> DATE CItY AND StArE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE,~OR STATE MEASURE PROPONENT <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONEN1 <br /> <br />FOR INFORMATION REQUIRED TO BE PROVIDED TO YOU PURSUANT TO THE iNFORMATION PRACTICES ACT OF 1977. SEE INFORMATION MANUAL ON CAMPAIGN DISCLOSURE ~ROVISIONS Of THE POLITICAL REFORM AL-[. <br /> <br /> State of California Fai~ Political Practices Commission <br /> <br /> <br />