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Recipient Committee <br />Campaign Statement <br />Cover Page <br />(Government Code Sections 84200-84216.5) <br />SEE INSTRUCTIONS ON REVERSE <br />Type or print In ink. <br />Statement covers period <br />from ~ ~/~ ~ <br />through /~ _3 // D <br />1. Type of Recipient Committee: All commltteea -complete Parta 1, z, 3, ana a. <br />officeholder, Candidate Controlled Committee ^ Ballot Measure Committee <br />Q Stale Candidate Election Committee Q Primarily Formed <br />Q Recall Q Controlled <br />(Aho Compete Pert S) Q Sponsored <br /> <br />^ General Purpose Committee (aso compere Pane) <br />Q Sponsored ^ Primarily Formed Candidate/ <br />Q Small Contributor Committee Officeholder Committee <br />Q Political Party/Central Committee laso compere Pen ~/ <br />3. Committee Information ~ I'D' <br />COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) <br />~/r!/~NA S <br /> s) <br />MAILING ADDRESS <br />333 T~ /rV ~Ol.~!-tit/ ,~ '~ 3.3b <br />Date Stamp <br />Date o(Month i Dayf Year) cabl A N 2 2004 ~ Page ~._ of S~ <br />J 1 <br />For Omcial Use Only <br />CITY OF REC'NG6D CITY <br />CITY CLc~K <br />2. Type of Statement: <br />:~ <br />^ Preelection Statement ^ puartedy Statement <br />Semi-annual Statement ^ Special Odd- <br /> <br /> Fonn 495 <br />STREET ADDRESS (NO P.O. BOX) <br />X33 ~win~ DG~- <br /> <br /> -boy - <br />MAII INC. ADDRESS ^F DIFFERENTI NO. D STREET OR P.O. BOX /_ /_ Q <br /> CODE/PHONE <br />OPTIONAL: <br /> <br /> ANY b 1~ <br />MAILING ADDRESS <br />CITY STATE 21P CODE AREA CODEIPHONE <br />~i5'o-~ 8d'~-t~Glo <br />OPTIONAL: FAX / E-MAIL ADDRESS <br />4. Verification <br />1 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. <br />certify under penalty of perjury under the laws of the State of Califomia that the f <br />Exewted on ~ Date b 7~ By <br />Executed on <br />oem <br />Executed on <br />Date <br />By <br />Exewled on ~ By Signame dCan6airg Officeholder, Candidate,SbLe Meewre P~oppiMd FPPC Fonn 460 (Junelot) <br />FPPC Toll-Free Hslplina: 668fASK-FPPC <br />Slate of Califomia <br />By SiOretureafCorxraarp OexehdUer, Ceneklete, Slate Meewre ProporeM <br />