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ecipient 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 />,rom I-Ct <br /> <br />COVE~ PAGE <br /> <br /> Date Stamp <br /> <br />Dste o, e~ectio, if 10 ~t 3: <br /> ! <br /> I <br /> (Month, Day, Year) ' Page <br /> ..... !~ ~.~.~ \O. For Official Use Only <br /> <br />1. Type of Recipient Committee: A, Committees - Complete Parts I, 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 />C) Small Contributor Committee <br />C) Political Party/Centra~ Committee <br /> <br />[] Ballot Measure Committee O Pdma~ly Formed <br /> O Controlled <br /> O Sponsored <br /> (Also Comp~te Pa~1 $) <br /> <br />[] Primarily Formed Candidate/ <br /> Officeholder Committee <br /> (Also Cc~p~ete Pat17) <br /> <br />3. Committee Information <br /> <br /> <br /> <br /> MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX <br /> <br />2. Type of Statement: <br />[] Preetection Statement [] Quarterly Statement <br />[] Semi-annuaIStatement [] Special Odd-Year Report <br />[] Termination Statement [] Supplemental Preelection <br />[~ Amendment (Explain below) Statement - Attach Form 495 <br /> <br /> Tre~su~r(s] <br /> <br />N OF TREA URER <br /> <br />NAME ~F-ASSISTANT TREASURER, IF ~Y <br /> <br />MAILING ADDRESS <br />CITY STATE ZIP CODE AREA CODE/PHONE <br /> <br />CiTY STATE ZIP CODE AREA CODE(PHONE <br /> <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 informalion 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 forego' correct. <br /> <br /> Executed on Dy <br /> Executed on By <br /> <br />Executed on By FPPC Form 460 (June/01) <br /> <br /> <br />