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Recipient Committee <br />Campaign Statement <br />Cover Page <br /> <br />(Government Code Sections 84200-84216.5) <br /> <br />SEEINSTRUCTIONS ON REVERSE <br /> <br />Type or print in ink. <br /> <br /> Statement covers period <br />,,om q <br /> <br />Date of election if applicable: <br /> (Month, Day, Year~-~ <br /> <br />Date Slamp <br /> <br />COVE~ PAGE <br /> <br />For Official Use Only <br /> <br />1. Type of Recipient Committee: AII Committees - Complete Parts l, 2, 3, and4. <br /> <br />[] Officeholde r. Candidate Controlled Committee <br /> O State Candidate Election Committee <br /> O Recall <br /> (Also Complete Part 5) <br /> <br />[] General Purpose Committee <br /> Sponsored <br /> Small Contributor Committee <br /> (~ Political Party/Central Committee <br /> <br />[] Ballot Measure Committee O Primarily Formed <br /> O Controlled <br /> C) Sponsored <br /> <br />[] Primarily 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 COMMITTEE) <br /> <br /> <br /> <br />MAILIN6 ADDflE88 (IF DIFFERENT~ NO. AND 8fREET OR P.O. BOX <br /> <br />Treasurer(s) <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />MAILING ADDRESS <br />CITY STATE ZIP CODE AREA CODE/PHONE <br /> <br />CITY STATE ZIP CODE AREA CODE/PHONE <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 true and complete I <br />certify under penalty of perjury under the laws of the State of California that the foregoing is true and~correct, <br /> - // <br /> Executedon ,-~'~/~/~' By I,/(~t~1~ //z.f~ <br /> <br /> <br /> By <br /> <br />Dale Signalum <~ C~ntmlling Officeholder. Candidate, State Measure Prcpene~t FPPC Form 460 (J une/01 ) <br /> FPPC Toll-Free Helpllne: 866/ASK*FPPC <br /> State of California <br /> <br /> <br />