HomeMy WebLinkAboutBUSTAMANTE 470 fficeholder and Candidate
Campaign Statement -- Short Form
(Gov~, nment Code Section 84206)
Type or print in ink.
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 who 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, arid Their Con~rolled
Committees for further information.
I
II
Statement Covers Calendar Year 19
Officeholder or Candidate Information
NAME OF OFFICEHOLDER OR CANDIDATE
RESIDENTIAL OR BUSINESS ADDRESS (NO AND STREET)
CITY
AREA CODE/DAYTIME PHONE NUMBER
Date Stamp
SHORT ~ORM
III Information on Office Sought or Held
OFFICE SOUGHT OR HELD
JURISDICTION (LOCATION)
STATE ZiP CODE DATE OF ELECTION (MONTH, DAY. YEAR) (IF APPLICABLE)
For Official Use Only.
O.
CLEF:?(
IDISTRICT NUMBER
(IF APPLICABLE)
IV
Committee Information
List ali committees of which you have knowledge that are primarily formed to receive contributions or to make expenditures on behalf of your candidacy.
COMMITTEI~ NAME AND I.D. NUMBER
V Verification
COMMITTEE ADDRESS
NAME OF TREASURER
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.
CItY ANb STATE -~ .... SlG~A1~m~ICE~E~R ~NDIOATE
FOR INFORMATION REQUIRED 10 BE PROVIDED TO YOU PURSUANT TO THE INFORMATION PRACTICES ACT OF 1977. SEE tNFORMAT!~_N.. MANIJIA[ ON CAMPAIGN DISCLOSL~R~ PROVISIONS O{: 'THE POLITI~,,AL REFORM
State of California Fair Political Practices Commission