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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 />,rD., I0-1- <br /> <br />through <br /> <br />Date of election if applicable: <br />(Month, Day, Year) <br /> <br />Date Stamp <br /> <br />COVEF~ PAGE <br /> <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 O State Candidate Election Committee <br /> O Recall <br /> <br />General Purpose Committee <br />~ Sponsored <br />O Small Contributor Committee <br />O Political Pa~j/Central Committee <br /> <br />[] Ballot Measure Committee <br /> O Primarily Formed <br /> O Controlled <br /> O Sponsored <br /> (A/so Ccmp~te Pa. ~) <br /> <br />[] Primarily Formed Candidate/ <br /> Officeholder Committee <br /> (Also Comp~te Pa. 7) <br /> <br />2. Type of Statement: ~ Prealection 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 /> <br />MAILING A D~I~SS <br /> <br />NAME OF ASSISTANT TREASURER, IF ANY <br /> <br /> <br /> <br />STREET ADDRES~ (No P.O, BO~ <br /> AREA CODE/PRONE <br /> <br />~" ~ ADDRESS (IF DIFFERENT} NO. AND STREET OR P.O. BOX ~AILIN6 ADDRESS <br /> <br />~T~ ~ 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 alt 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 foregoll~l is true .~nd correct. <br /> Executed on ~(1~"~b'¢--~¢'~- ~ By *~.¢~ ~~ <br /> <br /> <br />