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Recipient Committee <br />Campaign Statement <br /> <br />(Government Code Seclions 84200-84216.5) <br /> <br />Type or print in ink. <br /> <br />SEE INSTRUCTIONS ON REVERSE <br /> <br />Statement covers period <br /> <br />1. Type of Recipient Committee: ^, committees-Complete Parts 1, 2, 3, and 7. <br /> <br />[] Officeholder, Candidate <br /> Controlled Committee <br /> (Also Compiete Part 4.) <br /> <br />[] Ballot Measure Committee <br /> O Primarily Formed <br /> O Controlled <br /> O Sponsored <br /> (Also Complete Part 5.) <br /> <br />[] Primarily Formed Candidate/ <br /> Officeholder Committee <br /> (Also Complete part 6) <br /> <br />[] General Purpose Committee <br /> ~ Sponsored <br /> O Broad Based <br /> <br />3. Committee Information <br /> <br />~TREET ADDRESS {NO P.O. BOX) <br /> <br />MAILING ~DRESS (IF DIFFEREN~ NO. ~D STREET OR ~O. BOX <br /> <br />Date of election If applicable: <br />(Month, Day, Year) <br /> <br />Date Stamp <br /> <br />COVERPAGE <br /> <br />2. Type of Statement: <br /> <br /> [] Pre-election Statement <br /> [] Semi-annual Statement <br /> [] Termination Statement <br /> [] Amendment (Explain below) <br /> <br />Treasurer(s) <br /> <br /> <br /> <br />For Official Use Only <br /> <br />[] Quarterly Statement <br />[] Special Odd-Year Report <br />[] Supplemental Pre-election <br /> <br />Statement - At[ach Form 495 <br /> <br />NAME OF TREASURER <br /> <br />MAILING ADORESS <br />CiTY STA'I~ ZIP CODE AREA CODE/PHONE <br /> <br />CITY STATE ZIP CODE AREA CODE/PHONE <br /> <br />OPTIONAL: FAX I E-MAIL ADDRESS <br /> <br />OPTIONAL: FAX I E4~A~L ADDRESS <br /> <br /> FPPC Form 460 (8199) <br />For Technical Aeilstance: 916/322-5660 <br /> State of California <br /> <br /> <br />