Laserfiche WebLink
Recipient Committee <br /> Campaign Statement <br /> Cover Page <br /> (Government Code Sections 84200-84216.5) <br /> SEE INSTRUCTIONS ON REVERSE <br /> from <br /> through <br /> Type or print in ink. <br /> period I Date of election if applicable: <br /> -� (Month, Day, Year) <br /> 1. Typ@ Of R@Clpl@Ilt C01711711tt@@: All Committees—Complete Parts 7,z,z,and 4. <br /> [7�Officeholder,Candidate Controlled Committee ❑ Primarily Formed Ballot Measure <br /> Q State Candidate Election Committee Committee <br /> Q Recall Q Controlled <br /> (AlsoCompletePartS) � Sponsored <br /> (Also Complete Part 6) <br /> ❑ General Purpose Committee <br /> � Sponsored <br /> � Small Contributor Committee <br /> Q Political Party/Central Committee <br /> 3. Committee Information <br /> � Primarily Formed Candidate/ <br /> Officeholder Committee <br /> (Also Complete PaR 7) <br /> I.D. NUMBER <br /> � <br /> COMMITTEE NAME(OR CANDIDATE'S NAME IF NO COMMITTEE) <br /> �sa v�►� � ����- �z. �'� y ��� � ��. <br /> STREET ADDRESS (NO P.O. BOX) <br /> ��- <br /> CIT� STATE ZIP CODE <br /> � <br /> MAILING ADDRESS (IF DIFFERENT) NO.AN STREET OR P.O. BOX <br /> CITY <br /> OPTIONAL: FAX/E-MAIL ADDRESS <br /> STATE ZIP CODE AREA CO <br /> _:�� -.Bate�Famp <br /> ��� <br /> ;; �� * h <br /> ;� �� f�;,:�,f� � •� LO�� <br /> i:�Tl" ',� _,t ;_7..,,,._,,. ;�, <br /> .:t'�'. ��.s_':���. <br /> 2. Type of Statement: <br /> ❑ Preelection Statement <br /> ❑ Semi-annual Statement <br /> ❑ Termination Statement <br /> �Also file a Form 410 Termination) <br /> Amendment(Explain below) <br /> I . <br /> Treasurer(s) <br /> COVER PAGE <br /> of_ <br /> For Official Use Only <br /> ❑ Quarterly Statement <br /> ❑ Special Odd-Year Report <br /> ❑ Supplemental Preelection <br /> Statement-Attach Form 495 <br /> iUR R <br /> �� �rC� � C�,�,.� <br /> � � �—FOI� <br /> MAILING ADDRESS <br /> �`� ��� �--�. <br /> CITY STATE ZIP CODE EA CODE/PHONE <br /> �v�c�c� c� G'� �/ � <<<tC%(�S � � <br /> NAME OF ASSISTANT TREASURER. IF A <br /> MAILING ADDRESS <br /> CITY STATE ZIP CODE AREA CODE/PHONE <br /> OPTIONAL: FAX/E-MAIL ADDRESS <br /> 4. Verification <br /> I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the information contained herein and in the attached schedules is true and complete. I certify <br /> under penalty of perjury under the laws of the State of California that the foregoing is true and correct. <br /> Executed on <br /> Date <br /> Executed on <br /> Date <br /> Executed on <br /> Date <br /> Executed on <br /> Date <br /> By <br /> By <br /> By <br /> Signature of Controlling Officeholder,Candidate,State Measure Proponent <br /> By <br /> SignatureofControllingOfficeholder,Candidate,StateMeasureProponent pppC Fo�ri1460(January/O5) <br /> FPPC Toll-Free Helpline:866/ASK-FPPC(866/2753772) <br /> State of California <br />