HomeMy WebLinkAboutPALMER 470 SUPPLEMENT fficeholder and Candidate
Campaign Statement
Form 470 Supplement
(Government Code Section 84206)
SEE INSTRUCTIONS ON REVERSE
Type or print in ink.
This form is written notification that the officeholder/candidate listed below has received contributions totaling
$1,000 or more or has made expenditures of $1,000 or more during the calendar year.
Date Stamp
FEB i 6 ~i I0:27
FORM 4;/'0 SUPPLEMENT
For Official Use Only
I Officeholder or Candidate Information
NAME OF OFFICEHOLDER OR CANDIDATE
RESIDENTIALOR BUSINESSADDRESS ~.~ (NO. ANO STREET)
Cl~ STATE ZIP CODE
AREA CODE/DAYTIME PHONE NUMBER
II Information on Office Sought
OFFICE SOUGHT
DATE OF ELECTION (MONTH, DAY, YEAR)
III Date Contributions Totaling $1,000 or More Were Received or Date Expenditures of $1,000 or More Were Made
(MONTH, DA% YEAR) ~ ~
Officeholder and Candidate
Campaign Statement--Short Form
(Government Code Section 84206)
Type or print in ink.
For use by an officeholder, candidates who do not have a controlled committee and who do not anticipate
receiving $1,000 or moro in contributions and do not anticipate spending $1,000 or moro during the calendar
year. Officeholders whose salary is less than $100 per month and judges who have a controlled committee
may use this form under certain cimumstances. See the information Manual on Campaign Disclosure
Provisions of the Political Reform Act for Elected Officeholders. Candidates. and Their Controlled Committees
for further information.
I Statement Covers Calendar Year ;ixJ
Date Stamp
SHOBT FC'~RM
For Official Use Only
II Officeholder or Candidate Information
NAME OF OFFICEHOLDER OR CANDIDATE
RESIDENTIAL OR BUSINESS ADDRESS
(NO. AND STREET)
Illlnformation on Office Sought or Held
OFFICE SOUGHT OR HELD
JURISDICTION (LOCATION)
DISTRICT NUMBER
FAPPLICABLE)
DATE OF ELECTION (MONTH. DAY, YEAR) (IF APPLICABLE)
IV Committee Information
List all committees of which you have knowledge that are primarily formed to receive contributions or to make expenditures on behalf of your candidac~
COMMITTEE NAMEAND I.D. NUMBER COMMITTEEADDRESS NAME OFTREASURER
V Verification
I declare under penalty of perjury that to the best of my knowledge, I anticipate that I will receive less than $1,000 and that I will spend less than $1,000 during the
calendar year and that I have used all reasonable diligence in preparing this statement. I certify under penalty of perjury under the laws of the State of California
that the foregoing is true and correct., ' ' / ..~ ,~ ~ //
DA)CE ' C~TY ,~ND STATE"' / SIGNATURE OF OFFICEH~OLDER OR CANDIDATE
FOR INFORMATION REQUIRED TO SE PROVIDED TO YOU PURSUANT TO THE INFORMATION PRACTICES ACT OF 1977, SEE INFORMATION MANU
State of California Fair Political Practices Commission