470 Office Holder and Candidate Campaign Statement - Short Form Officeholder and Candidate � ��.��(C�`e���'P� �V� i� ' - . , �
Campaign Statement - ` • �
Short Form Date of election if applicable: ❑ qmendment �EXpia��eeioW� � j : For Offcial Use Oniy
(Month,Day,Year) Q�G ' �, qO�C
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CUPERT!(�!0 CITY ('I CRK '
1. Statement Covers Calendar Year 20 � �n .
2. Officeholder or Candidate Information 3. Office Sought or Held
NAME OF OFfICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
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STATE ZIP CODE
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AREA CODE/DAYTIME PHONE NUMBER OPTIONAL: FAX I E-MAILADDRESS
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 COMMITTEE ADDRESS NAME OF TREASURER
5. Verification
I declare under penalty of perjury that to the best of my knowledge I anticipate that I will receive less than$2,000 and that I will spend less than$2,000 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
I Clear Form I I Print Form I
' FPPC Form 470/470 Supplement(Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov