HomeMy WebLinkAboutNICITA SEMIANN97(2) fficeholder, Candidate,
and Controlled Committee
Campaign Statement -- Long Form
(Govern ment Code Sections 84200-84216.5)
SEE INSTRUCTIONS ON REVERSE
Check one of the following boxes to indicate the type of statement being flied:
Type M print In ink.
[] Pre~lection Statement
[] Supplemental Pre-election Statement (Attach e completed Form 495 to this statement.)
I"l Six/l~l Odd*Year Cam pAig n Report
[=~/1~mi-annuA1 Statement
[~ Termination Statement (Attach A completed Form 415 to this statement.)
Statement COVetS period
Date of election ff applicable:
{Month, Day. Year): '.: i.-
COVER PAGE - LONG FORM
I .Off. ice. ho. lder, Ca_ndidate, and Conliolled Com~i~ee
incluaea in this Statement
NAME OF TREASURER
Other Committees I )t Included in this Statement: u.,nyofha,
come/trees not included in thi~ consolidated statement that are controlled by you end
corem/fl'ecs of which you have knowledge that are l~merily formed to receive contributions
o~ to make expenditures on behalf of your cAnd/obcy.
AtIKh addltlonal lnformetlon on el~Oroprletely laboled contlnuatlon shae~
III Verification
I have used ell reasonable diligence in preparing this statement. I have reviewed the statement And to the ~ of my knowledge the tnformetion~onteiqed herein and tn the attached Khedules is
true add complete. ~corti~jM~Yderp~n~ty~fpe~[~u~yiVnd~rtf1~aw'~f/the~t~teofc~if~rniathatthef~reg~ingist/~e~nd~rrect~ _
Ex,¢,tedo. ,'4 - ' At ff ,,c . kD..F. ,K./ /
An offlceholdec M c~ndldete who conttMs e commlltol must elM) vMIfy lhe Campel~n stotement. I heve usod ell reasonebl~ diligence And TO the best of my knowledge the treasurer has used all
reasonable diligence in preparing this statement. I heve reviewed the stetement And to the best of my knowledge the information contained herein and in the attached schedules is true end
complete. I Certify under penalty of perjury under the laws of the Stete of Celifornia thet the foregoing is true end correct.
Executed on At By
DAT~ Crt(AND STATE S)GNATURE Of CA#~OATE~O. ICEHOrD~R
Executed on At By
DATE cn'Y AND STATE SIGNATURE Of CANDIOAIEK)F FICEKO~DEa
Executed on At By
DAIE CITY AND STATE S)GNAIURE Of CANDIOAT E)OFficE HOL Df
F rjr INFOfIMATION REQUIRED TO BE PROVIDED TO YOU fflJREUANT TO THE INFORMATK~I PRACTICES ACt Of lg 77, SE E fNFORMATK~I MAN~AL 4~1 CAMPAIGN DrSCLOSynE PROVrSK)NS Of THE POLITICAL RE FORM
State of Ca#fornie Fair Political Practices Commission
Campaign Disclosure Statement
Summary Page
SEE INSTRUCTIONS ON REVERSE
NAME OF OFFICEHOLDER OR CANDIDATE AND CONTROLLED COMMITTEE
Contributions Received
5. SUBTOTALCONTRIBUTIONS(Exd(deEnforceaMePromlses)
6. Enforceable Promises
(Exdm~e LOan Guarantees, Line la below)
..................
7. TOTAL CONTRIBUTIONS RECEIVED .....................
I. Monetary Contributions ............................... Schedu/e A, uno
2. Loans Received ......................................... S~bede/e
3. SUBTOTAL CASH CONTRIBUTIONS ...................... ,~ddUnesf
4. Non-monetary Contributions ......................... Schedu/e C Uno 3
,iddUnes3 +4 $
Aa~ItJMsS + 6 $
Expenditures Made
Type m' I)clnt Iff ink.
Amounts may be rounded
to whole doR~rs.
Column A
$
8. Cash Payments (Other than Loans Mede) ............ Sd~H~u/eE, UneS S
9. Loans Made ............................................. Sd~edu~e H, Uno 7
10. SUBTOTAL CASH PAYMENTS ............................ AddLl~esa
11. Accrued Expenses (Unpaid Bills) ..................... Sched~ F, Une S
12. TOTAL EXPENDITURES MADE ......................... AddUnes I0 * !1 $
Current Cash Statement
13. Beginning Cash Balance .................. PrevlousSummltyPlge, ~ 17 $
14. Cash Receipts ...................................... ColumnAUne3above
15. MiKellaneous Increases to Cash ........................ ScheduleI, LIne4
16. Cash Payments .................................... Co/umnA,
17. ENDINGCASH BALANCE ..... AddLInes 13
If thls lz i tennlnation st,atement, l.l, ne 17 must be zem.
18. LOANGUARANTEESRECEIVED .............. Schedule a, Pirr l, Column~b) S
Cash Equivalents and Outstanding Debts
19. Cash Equivalents ................................ see Itmrucf;om o~nsve~e
20. Outstanding Debts ................. AddUne 2 + Line ll tnCMumnCabove
SUMMARY PAGE
Column B*
(SEE
S
S
S
S
I.D. NUMBER
Column C
TOTAl. TO DATE
Summary for Candidates in Both June and
November Elections
II1 through ~/30 711 to Date
21. ~ontribqtions
Kecelvea . S
22.
nditures
I
* From previous Stltement Summary Page, Column C. However, if I
this is the first rer)o~ filed for the calendlr year. Column B should be
blink except for LOans Received (Line 2), Enforceable Promises (Lithe
6), LOans Made (L ne SI, ind Accrued Expensec (Line 11 ).
S
S
S
S
$