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Recipient Committee <br />Campaign Statement <br />Cover Page <br /> <br />(Government Cede Sections 84200-84216.5) <br /> <br />SEE~NSTRUCTIONS ON REVERSE <br /> <br />Type or print in ink. <br /> <br />Date Stamp <br /> <br />Statement covers period <br /> <br />through <br /> <br />Date of election if a <br /> (Month, Day, Year) <br /> <br />COVEI~ PAGE <br /> <br />For Officia~ Use Only <br /> <br />1. Type of Recipient Committee: All Committees - Complete Parts t, 2, 3, and 4. <br /> <br />[] Officeholder, Candidate Controlled Committee 0 State Candidate Election Committee <br /> O Recall <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 /> O Sponsored <br /> (AIsc Complete Part E) <br /> <br />[] Primarily Formed Candidate/ <br /> Officeholder Committee <br /> (Aisc Co.plate Pa~t 7) <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 />Treasurer(s) <br /> <br />NA E OF TREASURER <br /> <br />NAME OF ASSISTANT TREASURER, IF ANY <br /> <br />MAiLiNG ADDRESS (IF DIFFERENT} NO. AND STREET OR PlO. ~OX MAILING ADDRESS <br /> <br />CITY STATE ZiP CODE AREA CODE/PHONE CiTY STATE ZiP CODE AREA CODE/PRONE <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 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 /> Executed on By <br /> Executed on By <br /> <br />Executed on By <br /> <br />FPPC Toll-Free Helpllne: 8661ASK-FPPC <br /> Stale of California <br /> <br /> <br />