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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 /> Statement covers period <br />from I -- 1 --0(~ <br /> <br />,brough 2-1 ,-02 <br /> <br />Date of election if applicable: <br />(Month, Day, Year) <br /> <br />Date Stamp <br /> <br />iFIEL0 CiTY CLERK <br /> <br />COV~F~ PAGE <br /> <br />Page I of ~_.__ <br /> <br />For Official Use Only <br /> <br />1. Type of Recipient Committee: All Comminees - Complete Parts 1, 2, 3, and 4. <br /> <br />[] Officeholder, Candidate Controlled Committee <br /> O State Candidate Election Committee <br /> 0 Recall <br /> /Also Comple(e Pa~l 5) <br /> <br />[] General Purpose Committee ~ Sponsored <br /> O Small Contributor Committee <br /> O Political Party/Central Committee <br /> <br />[] Ballot Measure CommiTTee 0 Primarily Formed <br /> 0 Controlled <br /> 0 Sponsored <br /> /Also ComDtete Parr E) <br /> <br />[] Primarily Formed Candidate/ <br /> Officeholder Committee <br /> /Also CompS. re Part 7) <br /> <br />2. Type of Statement: <br /> <br /> ~. Preelection Statement <br /> [] Semi-annuai 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 />Treasurer(s) <br /> <br />NAME OF TREASURER <br /> <br />M~-LING ADDRESS <br /> <br />NAME OF ASSISTANT TREASURER, IF ANY <br /> <br /> <br /> <br /> <br /> <br />STREET ADDRESS (NO P.O. BOX) <br /> <br /> <br />MAILING ADDRESS (IF DIFFERENT) NO, AN~STR~ET OR P.O. BOX MAILING ADDRESS <br /> <br />CITY STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA CODE/PHONE <br />OPTIONAL: FAX / E-MAIL ADDRESS OPTIONAL: FAX / E-MAIL ADDRESS <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 <br /> ify under penalty of perjury unde <br /> <br /> ~ Signature of Treasurer or Assistarlt Treasurer <br /> Executed on By <br /> <br /> Executed on By <br /> <br />Executed on By <br /> <br />FPPC Toll-Free Helpllne: 8661ASK-FPPC <br /> State of California <br /> <br /> <br />