HomeMy WebLinkAboutTITUS 470 7/22/14Officeholder and Candidate
Campaign Statement -
Short Form
Date of election if applicable:
(Wnth, Day, Year)
—11-1- 1*
❑ Amendment (Explain Below)
Date Stamp
s
1. Statement Covers Calendar Year 20 AL -
2. Officeholder or Candidate Information 3. Office Sought or Held
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
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 �y , BY 1111111111-9 X
DATE SIGNATURE OF OFFICEHOLDER OR CANDIDATE
FPPC Form 470/470 Supplement (Jan /2008)
FPPC Form 470/470 Supplement Instructions - Rev. 2 (Dec /2012)
Clear 1•�"771 Print Form FPPC Advice: advice@fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
Officeholder and Candidate
Campaign Statement -
Form 470 Supplement
Amendment (Explain Below)
Date Stamp
For Official Use Only
SEE INSTRUCTIONS ON REVERSE
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.
1. officeholder or Candidate Information
NAME OF OFFICEHOLDER OR CANDIDATE
STREETADDRESS
CITY STATE ZIP CODE
AREA CODE/DAYTIME PHONE NUMBER OPTIONAL: FAX/ E-MAIL ADDRESS
2. Office Sought
OFFICE SOUGHT
(IF APPLICABLE)
OF ELECTION (MONTH, DAY, YEAR)
3. Date Contributions Totaling $1,000 or More Were Received or Date Expenditures of $1,000 or More Were Made
(MONTH, DAY, YEAR)
Clear Form, F+Fint Form FPPC Form 470/470 Supplement (Jan /2008)
FPPC Form 470/470 Supplement Instructions - Rev. 2 (Dec /2012)
FPPC Advice: advice@fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
Instructions for Completing
Form 470 Supplement
Form 470 Supplement:
If an officeholder or candidate files the Form 470
for an election year and later receives contributions
(including monetary and non - monetary contributions,
loans, and the candidate's personal funds) totaling
$1,000 or more or makes expenditures totaling
$1,000 or more during the same calendar year,
the officeholder or candidate must send a written
notice within 48 hours. Use the attached Form 470
Supplement or follow the instructions below for
preparing the notice.
When to File:
The notice must be sent within 48 -hours of receiving
contributions totaling $1,000 or more or making
expenditures of $1,000 or more.
Note: The 48 -hour notice requirement is applicable
only when the Form 470 is filed with a declaration of
candidacy or as a first pre - election statement.
Method of Delivery:
The notice must be sent by guaranteed overnight
delivery service, personal delivery, fax, or email.
Regular mail may not be used.
Where to File:
• Secretary of State's Office;
• local filing officer with whom the officeholder/
candidate is required to file the originals of his /her
campaign statements; and
• each candidate seeking the same office.
Contact your filing officer for candidate addresses.
Officeholder /Candidate Information:
Enter the officeholder /candidate's full name,
residential or business address and daytime telephone
number.
Office Sought:
• Enter the title of the office sought;
• the district number, if any; and
• the date of the election.
Date Contributions /Expenditures Were Made or
Received:
Enter the date monetary or non - monetary
contributions totaling $1,000 or more (including the
candidate's personal funds) were received or the date
expenditures of $1,000 or more were made.
Amendments: If you are filing an amendment to a
previously filed statement, give a brief explanation of
the amendment.
Note: Once an officeholder or candidate reaches
the $1,000 threshold in receipts or expenditures, in
addition to filing the Form 470 Supplement, other
forms are required. See FPPC Campaign Disclosure
Manual 1 for state candidates or
Manual 2 for local candidates.
FPPC Form 470/470 Supplement (Jan /2008)
FPPC Form 470/470 Supplement Instructions - Rev. 2 (Dec /2012)
FPPC Advice: advice @fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov