HomeMy WebLinkAboutMENSCH 470 10/12/12Of iceholder and Candidate
Campaign Statement —
Short Form
(Government Code Section 84206)
SCANNEL
101 V0 21 6yo
Type or print in ink.
Date of election if applicable: D Amendment (Explain Below)
(Month, Day. Year)
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1. Statement Covers Calendar Year 20 /.Z- .
Date Stamp
SHORT FORM
For Official Use Only
2. Officeholder or Candidate Information 3. Office Sought or Held
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
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STREET ADDRESS % JURISDICTION (LO ATION) {� DISTRICT NUMBER
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{IF AP LI ABLE
CITY STATE ZIP CODE (v
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ACO AYTIMEPHONENUMBER OPTIONAL FAXIE- MAITL_7�_DDRESS
4. 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 candidacy.
COMMITTEE NAME AND I.D. NUMBER I COMMITTEE ADDRESS I NAME OF TREASURER
5. 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.
Executed on C- 1 ' 0-1- — � "4- By
DATE SIGNATURE OF OFFICEHOLDER OR CANDIDATE
FPPC Form 4701470 Supplement (January/08)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (8661275 -3772)