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ecipient Committee <br />Campaign Statement <br />Cover Page <br />(Government Code Sections 84200-84216.5) <br /> <br />SEE INSTRUCTIONS ON REVERSE <br /> <br />Type or print in ink. <br /> <br /> Statement covers period <br /> <br /> <br /> <br />Date of election if applicable: <br />(Month, Day, Year) <br /> <br />Date Stamp <br /> <br />COVEF[ PAGE <br /> <br />1. Type of Recipient Committee: All Commiltees - Complete Parts 1, 2, 3, and 4. <br /> <br />[] Officeholder, Candidate Contmlled Committee <br /> 0 State Candidate Election Committee <br /> O Recall <br /> (Also Complete Pat15) <br /> <br />[] General Purpose Committee ~ Sponsored <br /> O Small Contributor Committee <br /> O Political Party/Central Committee <br /> <br />[] Ballott Measure Commdtee O Primarily Formed <br /> O Controlled <br /> O Sponsored <br /> (A lSD C~mpl~te Pa~t 6) <br /> <br />[] Primarily Formed Candidate/ <br /> Officeholder Committee <br /> <br />3. Committee Information <br /> <br />2. Type of Statement: <br />[] Praelection Statement [] Quarterly Statement <br />[] Semi-annuaIStatement [] Special Odd-Year Report <br />[] Termination StHement [] Supplemental Praelection <br /> <br /> Treasurer(s) <br /> <br />COMMITTEE NAME (OR CANDIDATE'S HAME IF NO COMMITTEE) NAM F TREASURER <br /> <br />MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX MAILING ADDRESS <br /> <br /> <br /> <br />CITY STATE ZIP CODE AREA CODE/PHONE <br /> <br /> <br />CITY STATE ZIP CODE AREA CODE/PHONE <br />OPTIONAL: FAX / E-MAIL ADORESS <br /> <br />4. Verification <br /> I have used all 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~erju~, under the laws of the Stats of California that the foregoing is true and correct. <br /> <br /> Ex.c.,.do. s, <br /> <br /> Executed on Dy <br /> Dale Signature Of Conlrolling Cfllcehotder, Candida/e. State Mea <br /> <br /> By FPPC Form 460 (June/0t) <br /> Executed on Dale Signalune ~ Cent rolling OIflceholde~, Cendidale, State Measure Prop(menl <br /> FPPC Toll-Free Relpllne: 866/ASK-FPP¢ <br /> State of California <br /> <br /> <br />