HomeMy WebLinkAboutNANCE 470 10/22/12Officeholder and Candidate Type or p&A in ink. Date SWrW
Campaign Statement -
Short Form Date of election if applk":
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1. Statement Covers Calendar Year 20 _22 .
2. Officeholder or Candidate Information 3. Office Sought or Held
werF nF nFFICBNOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
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FAX / E-MAIL ADD
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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
COMMrTEE ADDRESS
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 10 2 - 2 0 12— By
DATE
SIGNATURE OF OFFICEHOLDER OR CANDIDATE
FPPC Forth 470470 supplement (January/08)
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