460 Amendment ecipient Committee
Campaign Statement
Cover Page
(Government Code Sections 84200-84216.5)
SEE INSTRUCTIONS ON REVERSE
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Statement covers period
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from Date of election If applicable:
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1. Type of Recipient Committee: All committees -complete Parts 1, z, 3, and a.
Officeholder, Candidate Controlled Committee [] Primarily Formed Ballot Measure
Q State Candidate Election Committee Committee
Q Recall Q Controlled
(AlsoComple(ePad5) Q Sponsored
^ General Purpose Committee (Also Complete Pad 6)
Q Sponsored ^ Primarily Formed Candidate/
Q Small Contributor Committee Officeholder Committee
Q Political Party/Central Committee (Also Complete Pad 7)
3. Committee Information I I.°i~QE~
COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) =1
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STREET ADDRESS (NO P.O. BOX)
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CITY STATE ZIP CODE AREA CODE/PHONE
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MAILING ADDRESS (IF DIFFERE T) NO. AND STREET OR P.O. BOX
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CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX / E-MAIL ADDRESS
2. Type of Statement: ffl
^ Preelection Statement ~
^ Semi-annual Statement
^ Termination Statement
(Also file a Form 410 Termination)
,~ Amendment (Explain below)
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Treasurer(s)
COVER PAGE
of
For Official Use Only
stamen[
a dd-Year Report
^ Supplemental Preelection
Statement -Attach Form 495
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NAM OF TREASURER
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MAILING ADDRESS
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NAME t F ASSISTANT l
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STATE ZIP CODE
ANY
MAILING ADDRESS
CITY
STATE ZIP CODE
A~REA~CODE/PHONE
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AREA CODE/PHONE
OPTIONAL: FAX / E-MAIL ADDRESS
4. Verification
I have used all reasonable diligence in preparing and reviewing this statement and io
Executed on By
Dad Signature of Controlling Officehdder, Candidate, Stale Measure Proponent
Executed on gy
Date SignalureofConlmllingOfficehdder,Candidete,5lateMeasurepmponent FPPC Form 480 (Jenuery)OS)
FPPC Toll-Free Helpline: B681ASK-FPPC (8661275-7772)
State of California