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COVER PAGE <br />Recipient Committee Type or print In ink. Date Stamp <br />Campaign Statement <br />Cover Page <br />(Govemment Code Sections 84200-84216,5) <br /> Statement covers period Date of election If applica Page / of~ <br /> from ~ ~/~ (Month. O.~. ~"0 JAN ~ 1 Z004 ~o~ o.,~,., ~. o~ <br /> <br />SEE INSTRUCTIONS ON REVERSE through CITY CF ~F2'~¥OOD C~TY <br /> ' CiTY CLERK <br /> <br />1. Type of Eecipient CommiEee; All 6ommlttea~ - Complete ~a~s I, 2, 3, and 4, 2, Type of Statement: <br /> <br /> ~ OBceholder, Candidate Controlled Committee ~ Ballot Measure Committee ~ Preelection Statement ~ Quaderly Statement <br /> O State Candidate Election Committee O PdmadlyFo~ed ~Semi-annualStatement ~ Special Odd-Year Repod <br /> O Re~ll O Controlled ~ Te~ination Statement ~ Supplemen~l Preelection <br /> (AlsoC~pletePa~5) O Sponsored ~ Amendment (Explain below) Statement - Attach Fo~ 495 <br /> (~so Corette Pad 6) <br /> General Pu~ose Committee <br /> ~ O Sponsored Pdmadly Formed Candidate/ <br /> O Small Contributor Committee ~ Officeholder Committee <br /> O Political Pady/Cen~al Committee (Atso C~¢ete Pa~ 7) <br /> <br /> 3. Commiffee Information II'D' NUMBER ~?¢~ Treasurer(s) <br /> NA OF AS~ISTAN ,TbEASURER, I~ , "' <br /> OPTIONAL: FAX IE-MAIL ADDRESS OPTIONAL: F~IE- AL <br /> <br />4. Verification <br /> I have used all reasonable diligence In prepadng and reviewing this statement and to the best of m~ft,knowledge the information contained herein and in the attached schedules is true and complete. I <br /> certify under penalty of perjury under the laws of the State of Califomia that the foregoing is tm <br /> <br /> ,~ ~ - ' - SignalureofTreasureror ssisen rea~rer <br /> <br /> ~ ~te Signabre~ ~g~h~d~. C~e~, Slate Measure P~e~ ~ Res~si~e OBc~ ~ S~ <br /> Executed on By <br /> <br /> By FPPC Fo~ 460 (June/01) <br /> FPPC Toll-Free Helpllne: 8661ASK-FPPC <br /> State of California <br /> <br /> <br />