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DEr~:RT['i~'~OVER PAGE - LONG FORM <br /> ,..,.,"ana:~a'e, Type or print in ink. OITYOLERK ""~ <br />Officeholder, <br />and Controlled Committee Statement coverspariod <br />Campaign Statement -- Long Form f,om_ ?-I- <br />(Government Code Sections 84200-84216.5) JJ N <br />SEE INSTRUCTIONS ON REVERSE through <br />Check one of the following boxes to indicate the type of statement being filed: Date of election if applicable: For Official Use Only <br /> B (Month, Day, Year) <br /> Pre-election <br /> Statement <br /> Supplemental Pre-election Statement (Attach · completed Form 495 to this statement.) <br />[] Special Odd-Year Campaign Report <br />[] Semi-annual Statement <br />r'l Termination Statement (Attach ? completed Form 415 to this statement.) <br />I Officeholder. Candidate, and Controlled Committee II Other Committees I lot Included in this !,tatement: Ust any other <br />Included in this Statement corem/trees not includedin this consol/dated statement that are controlled by you and any <br /> committees of which you have knowledge that are primarily formed to receive contribut/om <br />NAME Of OFFICEHOLDER OR CA,~,D~ATE or to make expenditures on behelfof~our cand/datT. <br /> ~ ! ' COMMITEEE NAME I.D. NUMIER <br /> <br /> OFFICE SOUGHT O~ HELD (IM:LUOE LOC&TIO~ DI~TIUCT NUMIER I~ APIq,~) <br /> <br /> RESIDENTIAL O~ BUSINESS A~)ORESS / (NO. AND ST~ NAME OF TREASURER <br /> CITY STALE ZIP CODE AAL& COOEJ~AYTIME PHONE COMMITTEE ADDRESS MO. AND STRELrT) <br /> COMMITTEE NAME I I.D. NdbRER CITY STATE <br /> <br /> COMMITTEE ADDRESS MO. AND STREET) <br /> I <br /> I ZIP CODE AREA CODE/DAYTIME PHONE NAME Of TREASURER CONTROLLED COMM. <br /> CITY STATE <br /> <br /> COMMIT/EE ADO~ESS MO. AND STREET) <br /> NAME OF TREASURER <br /> <br /> PEI~IANENT ADDRESS OF TREASURER ' MO. AND STREET) CITY STATE ZIP CODE AKEA CODEA)AYTIME PHONE <br /> <br /> CITY STATE ZiP CODE AREA COOEa)AYTIME PHONE <br /> Attach add/t/onol informer/on on eppropr/ate/y labe/ed cont/nuadon sheets. <br /> <br />III Verification <br /> I have utad all reasonable diligence'in preparing this ~tatament. I have reviewed the statement and to the be~t of my knowi~lge the information contained herein and in the attached Khedule~ is <br /> true and complete. I certify under penalty of J~rjury under the le <br /> Executadon ~1:~)~)~' ' At ~ ~'~."~ ~' By~ <br /> ' CITY AND'SlaTE - · ~NATURE OF TREASURER <br /> <br /> An officehokler o(rJndidate who controls a committee must also verify the campaign statement. ~ have used all rea~n.able d!!ig, ence .an.~o..the_best o~! .my~now. lecl. ge. th.e tr.ea, sur. er. rhtas lUnSe~d all <br /> reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge, the~MC~aT~ COnT~F~O n~eln~ ~jl~t, ne attacneo scneoules ts ~ ue a o <br /> complete. Icertifyundqr panaltyof par~uryun~derthe~a~s~fthe~t~e~fC~a~if~/"qiathatthef~reg~ingistrueand~.A~t`rect.~/ / <br /> <br /> Executed on <br /> DATE CITY AND STATE~ ~ - ' SIGNATURE Of CANOIDATE/Of~ICEHC~.DER <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE OF CANDIDATE/OFFICEHOLDER <br /> <br /> Executed on At By <br /> DATE CITY AND STATE SIGNATURE Of CANDIDATE/OffiCEHOLDER <br /> <br /> FOR ~NFORMAT~N REOUtREO TO lE PROVIDEO TO ~OU PURSUAm ;O THE INfORMATK)N PR*CrEES AC~ O~ tg;;. SEE INFORMATION MANyRt ~N CAMPAIGN OISC[OSURE PROWSK)NS Of THE eoLnICA[ REFORM Acr <br /> <br /> <br />