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Recipient Committee <br />Campaign Statement <br /> <br />(Government Code Sections 84200-84216.5) <br /> <br />Type or print In Ink. <br /> <br />SEE iNSTRUCTIONS ON REVERSE <br /> <br />1. Type of Recipient Committee: AlI Commtttees - Complete Parts l, 2,3, and7. <br /> <br />Date of election If applica~llle: ~/ <br /> (Month, Day, Year)[~ ~' ~ <br /> <br /> I -Ol <br /> <br />2. Type of Statement: <br /> <br /> Date Slamp <br /> <br />"~CiTYCLEF <br /> <br />[] Officeholder, Candidate <br /> Controlled Committee <br /> (Also Complete Part <br /> <br />[] Ballot Measure Committee <br /> O Primarily Formed <br /> O Controlled <br /> O Sponsored <br /> (Also Complete Part S.) <br /> <br />[] Primarily Formed Candidate/ <br /> Officeholder Committee <br /> (Also Complete Part 6 ) <br /> <br />[] General Purpose Committee ~. Sponsored <br /> O Broad Based <br /> <br />~ Pre-election Statement <br />[] Semi-annual Statement <br />[] Termination Statement <br />[] Amendment (Explain below) <br /> <br />COVER PAGE <br /> <br />For Official Use Only <br /> <br />[] Quarterly Statement <br />[] Special Odd-Year Report <br />[] Supplemental Pre-election <br /> Statement - Altach Form 495 <br /> <br />3. Committee Information <br /> <br />COMMITTEE NAME <br /> <br /> <br /> <br /> <br /> <br />Treasurer(s) <br /> <br />NAME OF TREASURER <br />CITY <br /> <br /> <br /> <br /> <br /> <br />MAILING ADDRESS <br />CITY STATE ZIPCODE AREA CODE/PHONE <br /> <br />CITY STATE ZIP CODE AREA CODEJPHONE <br /> <br /> <br /> <br /> <br /> <br /> FPPC Form 460 (8199) <br />For T®chnlcal Assistance: 916/322-5660 <br /> State of California <br /> <br /> <br />