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Please type or print in ink. <br />NAME OF FILER (LAST) (FIRST) (MIDDLE) <br />\Z'--� A � �rv) <br />1. Office, Agency, or Court <br />Agency Name <br />Division, Board, Department, District, if applicable <br />Your Position <br />� tc_ I _ <br />® If filing for multiple positions, list below or on an attachment. <br />5. Verification <br />MAILING ADDRESS STREET CITY STATE ZP CODE <br />(Business or Agency Address Recommended - PubPc Document) <br />l certify under penalty of perjury under the laws of the State of California th <br />Date Signed / 1 — / z", 11 — Siginat <br />(month, l year) - le <br />FPP'C Form 700 (201012011) <br />FPPC Toll-Free Helpline: 866/275-3772 www,fppc.ca.gov <br />herein and in any attached schedules is true and complete. I acknowledge this Is a public document, <br />