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Type o, print Inink. . COVER ~AGE- LONG FORM <br />Office h gla nd Co n t rdolled Co m mittee er, Candidate, st.t.m..t coy. rs ~,.od Date Stamp <br />Campaign Statement -- Long Form ,,om.___~4~-----m ~ . ~ 7J--,%---~, ~. ~ ~~'~~ <br />(GovernmentC~eSe~lons84200-842165) throu-h ~/~/~7 ' j '~ ~ g U ~ <br />g ~ ; <br />TRUCTIONS ON REVERSE ' J I ILLL <br />SEE INS ~ ~ ~ . ~ I If~ " <br />~ Pre,lePton Statemem (~h, Day. Year) ~ ~ ~ UL ~ O ~ <br />~ Supplemental Pre~l~ion Statement (A~ach a completed Form 495 to th s statement.) <br />/I <br />~ Semi-annualStatemem , ~e~--" /I <br />~~ ~ate. an ontroe o~ee t er omm~tees.~ua~amm~ <br />~ ~g~ ~g ....... c~m~ees ~1 l~l~din ~ c~a~e~ ~aze~nl t~Z are c~zro,eo o~ yo Y <br /> Inc i~ ~dtem~flt c~m~ees of w~h you ~ve k~l~e lhal are ~ari~ f~m~ zo recewe <br /> ~AME OF OFF~EHO~ER OR ~M~ATE ~ ~o make executes ~ ~ofy~r <br /> ~N~L ~ BU~SS AD. SS (~, AND STM[~ ~M{ ~ 1~ASU~R <br /> ~y ' STATE ZiP C~ MA C~AYTNE ~ C~EE A~SS (~. AK ST~ <br /> LD. ~R ~ STATE <br /> COMMI~EE ~E I <br /> C~il ~SS ~. l~ Sl~E~ . <br /> ~ME OF TRE~U~R <br /> ~E~ ~SS ~ T~R ~. ~ ST~ET) <br /> A~ ~1 ~f~ma~ ~ ~i~te~ I~ c~tinuatl~ ~e~, <br /> <br /> III Verification <br /> ,have used .,, reasonable diligence in preparing this statement. , have. ,.wv?wed t.he_ st.a. temen..t and. to.the be~ of. m_y k~n_o_W~lceodrgr~.e inform, atio~n contained here.~nd~ the ..ached schedules is <br /> trueand~p~te~er~ify~nd~rP~n~ty~f~r~uryunderth~a~s~th~$t~i~e~a~T~rni~m~ttheT~r~mng~sTr~J)~U~ e~,. ~ / ~ /j <br /> <br /> ' //I~TE 01Y AND STkTE MGNATURE OF TREASURER <br /> <br /> An officeholder m undkJ&te wl~o controls I committle must also verify th campaign statement. I have used all reasonable diligence ancL~o the best of my knowledge the treasurer has used all <br /> complete. I certify ~nder i~Bnalty of perjury under the laws of the State o~California ~ ~e foregoing is true and c~r~/ct~.// //~ ////. ~ <br /> <br /> E~ecuted on At By <br /> DATE CiTY AND STARE SIGNATURE OF ~NDIDATE/OFFICEHOLOER <br /> <br /> Executed on At By <br /> DATE CITY AND SIAT[ $1GNAIURE Of CANDIDATE/OFFICEHOLDER <br /> <br /> FOR INFOI~4ATION I~(~/II~D ro ~E PROVIDED TO YOU PURSUAN] TO TH~ INFO~A~I~ P~lCiS A~ OF 1~7. S[i INFO~MA1 ION MAN~AL ~N ~MPAIGN DISCLOSUR[ PROVISIONS OF l Hi POLfl~L ~t~O~M A~ <br /> <br /> <br />