470 Annual
Officeholder and Candidate
Campaign Statement -
Short Form
(Government Code Section 84206)
Type or print in ink.
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Date of election if applicable: D Amendment (Explain Bel
(Month, Day, Year)
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1. Statement Covers Calendar Year 20 ~ .
2. Officeholder or Candidate Information
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STREET ADDRESS
3. Office Sought or Held
OFFICE SOUGHT OR HELD
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(LOCATION)
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DISTRICT NUMBER
(IF APPLICABLE)
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CITY
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STATE ZIP CODE
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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 LD. NUMBER COMMITTEE ADDRESS NAME OF TREASURER
5. Verification
I declare under penalty of perjury that to the best of my knowledge I anticipate that
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FPPC Form 470/470 Supplement (January/OS)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)