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Recipient Committee <br />Campaign Statement <br />Cover Page <br />(Government Code Sections 84200-84216.5) <br /> <br />SEE iNSTRUCTIONS ON REVERSE <br /> <br />Type or print in ink. <br /> <br />Dale Stamp <br /> <br /> Statement covers period <br /> <br />from ~ _ __ <br /> <br />Date of election if applicable: <br /> (Month, Day, Year)0~ ,J <br /> <br />COVEI~ PAGE <br /> <br />Page I of _~.~ <br /> <br />For Official Use Only <br /> <br />1. Type of Recipient Committee: All Committees - Complete Parts 1, 2, 3, and 4. <br /> <br />[] Officeholder, Candidate Controlled Committee <br /> O State Candidate Election Committee <br /> O Recall <br /> (Aisc Comp~ate Part 5) <br /> <br />[] Gene ral Purpose Committee (~ Sponsored <br /> 0 Small Contributor Committee <br /> O Political Party/Central Committee <br /> <br />[] Ballot Measure Committee <br /> 0 Primarily Formed <br /> O Controlled <br /> O Sponsored <br /> ~Also Ccmplete Part 6) <br /> <br />[] PdmaHly Formed Candidate/ <br /> Officeholder Committee <br /> <br />2. Type of Statement: <br /> [] Preelection Statement <br /> [~ Semi-annual Statement <br /> [] Termination Statement <br /> [] Amendment (Explain below) <br /> <br />[] Quarterly Statement <br />[] Special Odd-Year Report <br />[] Supplemental Preelection <br /> Statement - Attach Form 495 <br /> <br />3. Committee Information <br /> <br /> COMMITTEE NAME (OR CANDIDATE'S NAME IF NO ~OMMITTEE) - <br /> <br /> . l <br /> <br /> STREET ~RESS (NO P.O. ~OX) ~ <br /> <br /> CITY , ~ STATE /.~IP CODE AREA CODE/PHONE <br /> <br /> MAILING'ADDRESS (IF DIFFERENT) ~O, A~ ~REET OR P.O. ~OX <br /> <br />Treasurer(s) <br /> <br />NAME. OF TREASURER <br /> <br />NAME OF ASSISTANT TREASURER, IF ANY <br /> <br />AREA CODE/PHONE <br />./, l 7 <br /> <br />MAILING ADDRESS <br />CITY STATE ZIP CODE AREA CODE/PHONE <br /> <br />CITY STATE ZIP CODE AREA CODE/PHONE <br /> <br /> OPTIONAL: FAX/ E-MAIL ADDRESS OPTIONAL: FAX / E-MAIL ADD~.~ <br /> <br />4. Verification <br /> I have used all reasonable diligence in preparing and reviewing this statement and to the best of my knowledge the information contained herein and in the attached schedules is lrue and complete. I <br /> certify under penalty of perju~ under the laws of the State of California that the foregoing/,~ true and correct. ~ <br /> <br /> ' ' ~ S/~l~ture ol Treasure~ or Assistant Treasurer <br /> Executed on By <br /> <br /> Executed on By <br /> <br />Execuled on By <br /> <br /> <br />