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Recipient Committee <br />Campaign Statement <br />Cover Page <br />(Governmen~ Cr)de Sections 84200 842165) <br /> <br />SEEINSTRUCTIONS ON REVERSE <br /> <br />Type or print in ink. <br /> <br />Date Stamp <br /> <br />Statement covers period <br /> <br />Date of election if applicable; <br />/Mon. , Day, Year0 -3 Pt'I I: <br /> <br />BAKERS I£L9 CI'IY CI. ERK <br /> <br />COVER PAGE <br /> <br />Page[ of [''~ <br /> <br />For Official Use Only <br /> <br />1. Type of Recipient Committee: All Committees - Complete Paris 1, 2, 3, and 4. <br /> <br />[] Officeholder, Candidate Controlled Commitlee O State Candidate Election Commiltee <br /> O Recall <br /> <br />[] General Purpose Committee ~ Sponsored <br /> O Small Contributor Committee <br /> O 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 /> <br /> [] Preelection Statement <br /> [] Semi-annual Statement <br /> bi 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. Committeelnformation I D~(;I <br /> COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) <br /> <br />Treasurer(s) <br /> <br />N E OF TREASURER <br />MAILING/~'ECS <br /> <br /> <br /> <br /> <br /> <br /> __ ,-- -- <br /> <br />MAILING ADDRESS {IF DIFFERENT) NO. AND STREET OR P.O. BOX MAltING ADDRESS <br /> <br />CITY STATE ZIP CODE AREA CODE/PHONE C~TY STATE ZIP CODE AREA CODE/PHONE <br />OPTIONAL: PAX / E-MAIL ADDRESS OPTIONAL: FAX / E- <br /> <br /> <br /> edg herein and iR the attached schedules is true and complete. I <br /> certify under penalty of I~erjun~ under the laws ot the State of California that the foregoinQ is true and correct. <br /> <br /> / S~nalure of Treasurer or Ass{stan, Treasurer <br /> Executed on By <br /> <br /> Executed on By <br /> <br /> Executed on By <br /> FPPC Toll-Free Helpllne: 8661ASK-FPPC <br /> <br /> <br />