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RECIPIENT COMMITTEE <br /> STATEMENT OF TERMINATION <br />Recipient Committee WHERE TO FILE: <br /> Date <br /> Stamp <br />Statement of Term in ation F.o 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 fm'm 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 ILO. NUMBER NAME OF TREASURER <br /> <br /> ~'~/h d~,,~ P.~ ~ ~ ' ~'~1'~~~I MAILIN~ ADDRESS OF TREASURER NO. ANDSTREET <br /> <br /> ADDRES~bF COMMITTEE ~ NO. AND~ITREET <br /> /~ ~? ~, ~ ~- CITY STATE ZIP CODE <br /> CITY STATE ZiP CODE <br /> pla~ iiMBER CX~ ~ / AREA CODE~AYTIME PHONE NUMBER <br /> AREA CODE~AYTIME <br /> {~ / ~ ) _5- ~ ¢ - ~ ~ ~ / III Effective Date of Termination <br /> DATE FILING OBLATIONS WERE COMPLETED <br /> , , <br />I~ ~erifir~tion <br /> <br /> 8. lhi~ ~ommitt~ d~ not ~nti{ip~t~ r~i~in~ {ontdbution~ or m~kin~ ~nditur~ in the ~utur~; <br /> <br /> lhi~ rommitt~ ha, ~limin~t~d or d~{l~r~ th~t it h~ no intention or ~bilit~ to di~h~r¢~ ~ll d~bt~, Io~n~ r~{~i~d, ~nd other <br /> lhi~ ~ommitt~e h~ no ~urplu~ ~und~; <br /> <br /> I h~ u~ed ~ll r~,~on~bl~ dilio~n~ in pr~p~rin~ thi~ ~t~t~m~nt. I h~ r~i~ed th~ ~tat~m~nt ~nd to th~ ~t o~ m~ kno~l~d~ th~ information ront~in~d <br /> <br /> Execut~ on At By <br /> DATE CITY A~ STATE S~TU~ ~ TREASURER <br /> <br /> OA~ S1~1 ~T~ C~I~L~ ~F~E~DE~ ~N~DATE. ~ S1AIE MEASURE <br /> <br /> E~ecuted on. At By <br /> DAlE OIlY AmD SIAIE S~1~ ~ C~TR~LI~ ~E~DER, ~AIE. ~ SIAIE MEASU~ <br /> <br /> Executed on At By <br /> <br />I~ INF~MAIIOa REQUIRED 10 It PROVIDED TO YOU PURSUAN1 TO 1HE INFORMATION P~CI~ES AC1 ~ 1~77. SEE IN~MA11ON MAN~AL ON ~MPA~N D SCL~UR~ PRQVISIONS ~ 1HE POLITICAL REF~M <br /> <br /> State of ~lifmnia Fair political P~actices Commission <br /> <br /> <br />