HomeMy WebLinkAboutHEAP PREELEC00(2) fficeholder and Candidate
Campaign Statement -- Short Form
(Government Code Secbon 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 Cam
Disclosure Provisions of the Political Reform
Committees for further information.
Date Stamp
,~ ~CLU ~Ji F
SHORT FORM
For Otfici~l Use Only.
I Statement Covers Calendar Year 19 --
II
Officeholder or Candidate Information
NAME OF OFFICEHOLDER OR CANDIDATE
RESIDENTIAL OR BUSINESS ADDRESS (NO AND STREET)
CITY STATE ZIP CODE
AREA CODE/DAYTIME PHONE NUMBER
Ill Information on Office Sought or Held
OFFICE SOUGHT or HELD
JURISDICT~N (LOCATION) DISTRICT NUMBER
(IF APPLICABLE)
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 conthbutions or to make expenditures on behalf of your candidacy.
COMMITTEE NAME AND ID NUMBER COMMITTEE ADDRESS NAME OF TREASURER
V
Verification
I declare under penalty of perjury that to the best of m~. knowledge, I anticipate that I will receive less than $1,000 and that ) will spend less than $1 000 during
the calendar year and that I have used all reasonable ddigence in preparing this statement. I ce..~ify t/nder penalty 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 p;int 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.
I Officeholder or Candidate Information
Date Stare p
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
OFF~ESOUGHT
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)