Laserfiche WebLink
Recipient Committee <br />Campaign Statement <br />Cover Page <br /> <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 ID-t- 00%___ <br />th,o. h Io-Iq-O __ <br /> <br />Date of election if applicable: <br /> (Month, Day, Year) <br /> <br />Date Slamp <br /> <br />COVEF~ PAGE <br /> <br /> Page / of~ <br />~" I: '~ <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 /> 0 State Candidate Election Committee <br /> 0 Recall <br /> (Also Complete Part 5) <br /> <br />[] General Purpose Committee <br /> ~. Sponsored <br /> O Small Contributor Committee <br /> (~ Political Pady/Central Committee <br /> <br />[] Ballot Measure Committee O Primarily Formed <br /> O Controlled <br /> O 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 />Treasurer(s) <br /> <br />NAME OF TREASURER <br />MAILING A[~SS <br /> <br /> <br /> <br /> <br /> <br /> <br /> AREA CODE/PHONE <br /> <br />MA~ I~lq ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX MAILING ADDRESS <br /> <br />~'~T~ STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA CODE/PHONE <br />OPT{ONAL: FAX / E-MAIL ADDRESS OPTIONAL: FAX / E MAIL ADDRESS <br /> <br />4, Verification <br /> I have used all reasonable diligence in preparing add reviewing this statement and to the best of my knowledge the information contained herein and in the attached schedufes is true and <br /> <br /> <br /> J ~ S~gna~ure of Treasurer or Assistant Treasurer <br /> Executed on By <br /> <br /> Dy <br /> <br />Executed on <br /> <br />Date <br /> <br />By <br /> <br /> <br />