HomeMy WebLinkAboutPALMER 470 fficeholder and Candidate
Campaign Statement -- Short Form
(Government Code Section 84206)
Type or print in ink.
Date Stamp~
SHORT'FORM
For use by officeholders and candidates who do not have a controlled committee and who do not anticipate
receiving $1,000 or more in contributions and do not anticipate spending $1,000 Or more during the
calendar year. Officeholders whose salary is less than $100 per month and judges wh° have a controlled
committee may use this form under certmn circumstances. See the Information Manual on Campaiqn
DisclosUre Provisions of the Political Reform Act for Elected Officeholders, Candidates, and Their Controlled
Committees for further information,
I
II
Statement Covers Calendar Year 1~ ~ ~O. 0
Officeholder or candidbte Information
NAME OF OFFICEHOLDER OR CANDIDATE
RESIDENTIAL OR BUSINESS ADDRESS (NO. AND STREET)
CITY STATE
ZIP CODE
For Of ficiial Use Only,
001 12:O0
~ t~:Lb CiTY CLERE
III Information on Office Sought or Held
OFFICE SOUGHT OR HELD
JURISDICTION (LOCATION~)
DATE OF ELECTION (MONTN, DAY, YEAR) (IF APPLICABLE)
DISTRICT NUMBER
(IF APPLICABLE)
IV Committee Information
List all committees of which you have knowledge that are primarily formed to receive contributions or to make ex
COMMITTEI~ NAME AND 1.1~. NyMBER
(~(~MMITTEE ADDRESS
~enditures on behalf of your candidacy.
NAME OF TREASURER
V Verification
I declare under penalty of peri ury that to the best of m)( knowledge, I anticipate that I will receive less than $1,000 and that I will spend less than $1 ,()00 during
the calendar year and that I have used all reasonable ddigence in preparing this statement, cert fy under pena ty of perjury under the laws of the State Of
California that the foregoing is true and correct.
State of California Fair Political Practices Commission
Officeholder 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.
Officeholder or Candidate Information
Date Stamp
FORM 470 SUPPLEMENT
For Official Use Only
NAME OF OFFICEHOLDER OR CANDIDATE
RESIDENTIAL OR BUSINESS ADDRESS (NO. AND STREET)
CITY STATE
ZIP CODE
AREA CODE/DAYTIME PHONE NUMBER
II Information on Office Sought
OFFICE SOUGHT
DATE OF ELECTION (MONTH, DAY, YEAR)
DISTRICT NUMBER
(IF APPLICABLE)
III Date Contributions Totaling $1,000 or More Were Received or Date Expenditures of $1,000 or More Were Made
(MONTH, DAY, YEAR)