HomeMy WebLinkAboutNICITA ST fficeholder and Candidate
Statement of Termination
This form must be completed by officeholders and
candidates that are eligible to terminate pursuant
to Government Code Section 84214.
Type or print in ink.
F LE
WHERE TO FILE:
Officeholders and candidates must file
Form 416 with the filing officer with
whom they filed their original campaign
statements (Form 470 or 490).
OFFICEHOLDER AND CANDIDATE
STATEMENT OF TERMINATION
I Officeholder or Candidate Termination
NAME OF OFFICEHOLDER OR CANDIDATE
RESIDENTIAL OR BUSINESS ADDRESS
NO. AND STREET
CITY STATE ZIP CODE
AREA CODE/DAYTIME PHONE NUMBER
II Office Sought or Held
OFFICE SOUGHT OR HELD FOR WHICH YOU ARE FILING THIS STATEMENT
JURISDICTION (IF APPLICABLE)
III Effective Date of Termination
DISTRtCT~MBER (IF APPLICABLE)
DATE FILING OBLIGATIONS WERE COMPLE ED
IV Verification
For the office listed in Part II of this form, I verify that:
A. I do not hold or am no longer a candidate for the office;
B. I have ceased to receive contributions and make expenditures;
C. I do not anticipate receiving contributions or making expenditures in the future;
D. ~ have e~iminated ~r ~ dec~are that ~ have n~ intenti~n ~r abi~ity t~ discharge a~~ debts~ ~~ans received~ and ~ther ~b~igati~ns;
E. I have no surplus campaign funds; and
F. I have filed all campaign statements required by the Political Reform Act disclosing all reportable transactions.
I have used all reasonable diligence in preparing this statement. I have reviewed the statement and to the best of m/~owledge the information contained
herein is true and complete. I certify under penalty of perjury under the laws of the State of California that the~g is true and correct.
Executed on '~ At :~ ~'-?'~:~,.~ s~ SIG"ATUR' OF O'FICEHOLO'' OR CANO~ --
FOR INFORMATION RFOUJRED TO ~E PROVIOE D TO YOU PURSUANT TO THE INFORMATION PRACTICES ACT OF lg77, SEE INFORMATION MANUAL ON CAMPAfGN DISCLOSURE PROVIS iONS OF THE POLITICAL REFORM ACT
State of California Fab Political Practices Commission