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Officeholder, Candidate, Type or print in ink. ~ COVER PAGE- LONG FORM <br />and Controlled Committee Statemant¢ovarsperiod DateStamp <br />Campaign Statement -- Long Form ? ,i: <br />(Government Code Sections 84200-84216.5) ~' <br /> <br />SEE INSTRUCTIONS ON REVERSE through ~'~' :~)~ L~ ~ L~ :? Pa~l / of <br />Check one of the following boxes to indicate the type of statement being filed: Date of election if <br /> Pre-election Statement (Month. Day. Year) !L ~ ~ :~' ;: ~: For Official Use Only <br /> fi Supplemental PrHlection Statement (Attach a completed Form 495 to this statement.) i <br /> SpecialOdd-YaarCimpaignReport · ! ~, ~,,, ~.. <br /> Semi-annual Statement ~/~ i 0~ r~.u~ ~ ~ <br /> Termination Statement (Attach a completed Form 415 tothis statement.) ~ (~I~Y CL~RK <br /> tatement: <br /> In~ lis Statement corem/flees not included in this consolidated statemer~ that are controlled by you and any <br /> NAME OF OFFICEHOLDER OR CANI~DATE corem/trees of which you have knowledge that are primar#y formed to receive contdbutiom <br /> ~// ~/./~t~,&~) c~. ~ ~"~/~ ' or to make er~oenditures on behalf of your candid~. I <br /> COIdldlTTEE NAME I.D. #UMIER <br /> O~FICE SOUGHT oe HELD (INGUI)E LOCATION AND DISTRICT MUMMR I~ AII~LICABLE) <br /> <br /> RESIDENTIAL OR BUSINESS ADOI~SS ' (ldO. AND STR~LrT) ' NAME ~ TREASURER CONTROLLED COMMITTEE1 <br /> STATE CoMMnTEE ADDI~SS <br /> COMMITTEE NAME LD. NUMIi~R CITY STATE Zle CODE AREA COUEJOAYTiME <br /> <br /> , COMMITTEE NAME I I.D. NUMBER <br /> COMMITTEE ADDRESS (NO. AND STMET) <br /> I <br /> CITY STATE ZiP CODE W COOEK)AYTIME I'flONE NAME Of TREASURER COfaTROLLED COMMITIEE? <br /> <br /> N~ME OF TREASURER ' - COMIdlTTEE ADD. SS (NO. AND STREET) <br /> IIfRMARENT ADDRESS Of TREASUI~R (IK). AND STREET} CITY STATE ZIP COO~ AliSA COOEfl)AYTIME IlflONE <br /> <br /> CITY STATE ZI~ CODE AnEA COOM)AYTIME <br /> AKKh additional information on approprAate/y/abe/edcont/nuadon shield. <br /> <br /> i <br />III Verification <br /> I have used ell reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the ihformation contained herein and in the attached schedules is <br /> true and corn plate. I cqrtify under penalty of pequry under the laws of the State of California that the foregoing is! <br /> Ex.cutedon ' At <br /> · DATE ClT9 AND STATE ~NATUI~ Of TREASUP, ER <br /> An officeholder or candidate who controls a committee must also varify the campaign statement. I have used all reasonable diligence and to the best of my knowledge the treasurer has used all <br /> reasonable diligence in preparing this statement, i hive reviewed the statement and to the best of my knowledge the in(o.~)~, tion c~l~tain~l her~.ein/a~d in the ittached schedules is true and <br /> complete. I certif~L under penalty of perjury under the laws of the State of California that the foreg°ing is true and cor~'~;/// // <br /> Executed on ~b~/~ At <br /> OATS cnY A~O STATE S~GN~TUe~ of C~NDiO*rUOfF~EHOtDEA <br /> Executed on At By <br /> DATE CnY ANO s~ArE S~GNRrUX[ of C~NOIDA~UOf~[[HOtO~A <br /> <br /> Executed on At By <br /> 0ATE cnY AND STATE S~aN~Ue[ of CANmOATE~).~EHOtO~A <br /> <br /> ~Oa ~N~ORMAr~N aEqUi~O TO IE ~AOWDEO TO YOU eUeSUAm TO <br /> <br /> <br />