470 Annual
Officeholder and Candidate
Campaign Statement -
Short Form
(Government Code Section 84206)
Date 01 election ilapplicable:
(Month, Day, Vear)
0 Amendment (Explain Belo
Type or print In Ink.
1. Statement Covers Calendar Year 20~.
2. Officeholder or Candidate Information
3. Office Sought or Held
OFFICE SOUGHT O~
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AREA CÒDEI IIIYTIME PHONE NUMBER OPTIONAL: FAX IE-MAil ADDRESS
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4. Committee Information
List all committees of which you have knowledge that are primarily formed to receive contributions or to make expenditures on behalf of your candidacy.
COMMITTEE NAME AND I.D. NUMBER I COMMITTEE ADDRESS I NAME OF TREASURER
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5. Verification
I d~clare under penalty of perjury that to the best of my knowledge I anticipate that I will receive less than $1,000 and that I will spend less than $1,000 during
the calendar year and that I have used all reasonable diligence in preparing this statement. I certify under penalty of perjury under the laws of the State of
California that the foregoing is true and correct.
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FPPC Form 450 (JuneIO1)
FPPC Toll-Free Helpline: 866/ASK-FPPC