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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 />from <br /> <br />1. Type of Recipient Committee: All Committees- Complete Parts 1.2, 3, and 7. <br /> <br />[] Officeholder, Candidate <br /> Controlled Committee <br /> (Also Complete Pa,'f 4.) <br /> <br />[] Ballot Measure Committee <br /> O Primarily Formed <br /> O Controlled <br /> O Sponsored <br /> (Aisc Complete Par1 <br /> <br />[] Pdmadly Formed Candidate/ <br /> Officeholder Committee <br /> (A/so Complete Par~ 6) <br /> <br />[] Generel Purpose Committee <br /> (~ Sponsored <br /> O Broad Based <br /> <br />Date of election If applicable;- <br /> (Month, Day, Year) L <br /> <br /> Date Stamp <br /> <br />':~!:,:, ri C',;'¥ CL <br /> <br />2. Type of Statement: <br /> [~ Pm-election Statement <br /> [] Semi-annual Statement <br /> [] Termination Statement <br /> [] Amendment (Explain below) <br /> <br />COVERPAGE <br /> <br />For Of Scial Use Onty <br /> <br />[] Quarterly Statement <br />[] Special Odd-Year Report <br />[] Supplemental Pre-election <br /> Statement - Attach Form 495 <br /> <br />3. Committee Information <br /> <br /> <br /> <br /> <br /> M~LING ~DRESS (IF DIFFERE~ NO. ~D STREE~ OR RO. BOX <br /> <br />Treasurer(s) <br /> <br />NAME OF TREASURER <br /> <br /> <br /> <br /> <br />MAILING ADORESS <br />CITY STATE ZIP CODE AREA CODE/PHONE <br /> <br />CITY STATE ZiP CODE AREA CODE/PHONE <br /> <br /> <br /> <br /> <br /> <br /> <br /> FPPC Form 460 (8199) <br />For TechnicM Aeelltance: 916/322-5660 <br /> State of California <br /> <br /> <br />