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COVER PAGE -- LONG FORM <br />Recipient Committee Type or Print In ink. Sit"_:=_: ~l cover~ period Dale Stamp <br /> <br />Campaign Statement- Long Form I '-- /~/~ ~~ ~: <br />(Oove~cn~ C~e S~o~ 842~-~216.5) - - ' <br /> <br />~ P~e-el~tion Sl~t~ ~ Sea-annual Slatement <br />~ Special ~d-yea[ C~aign Repofl (Mont~ Day, Y~ar] G~ OF ~[~WO0~ CI <br />~ Suppl~ent~ Pre-elation State~nt (A~ach a c~leted Form 495 to this state.hi.) ~ ~1~ CLERK <br />~ Te[~naion Slale~nt (Aaach a c~eted Fmm 415 to lhis statement.) <br /> <br /> Committee Ifllormaffon il Primarily Formed Committee (See definition on reverse.) <br /> List names of officeholder(s) or candidate(s) for which this <br /> ~co~,..: committee is primarily formed <br /> (C~ck Bo~s) St~ ~finitio~ ~ ~rt~t ~tion on re~rst. <br /> Is ~i~ a s~ commits? ................................... ~ Ye~ ~ No <br /> ls~isaM~lifi~mit~ ................... ~ Ye~ ~ No <br /> Verifioallon <br /> I ~w u~ all r~blo diligc~ in prcp~ng ~s sm~mcnt ~d 1o thc ~st of m~ k~wl~gc ~ inflation ~n~i~ herein and in ~e al~h~ schedul~ is ~ and <br /> ~iE Sm~T~ ~ T~A~R <br /> E~u~ ~ ~ <br /> <br /> <br />