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Recipient Committee <br />Campaign Statement <br />(Government Code Sections 84200 - 84216.5) <br />from <br />Type or print in ink. <br />Statement covers period Date of election if applicable: <br />07/01/2009 (Month, Day, Year) <br />Ote Stamp <br />IECEIVE <br />JAN 2 2 2010 <br />COVER PAGE <br />CALIFORNIA,��±O <br />2005/06 vv <br />'FORM <br />1/13 <br />For Official Use Only <br />City of RiveTSide <br />SEE INSTRUCTIONS ON REVERSE <br />through 12/31/2009 <br />11/06/2007 <br />Ci!`7 trCle k's tide <br />1. <br />Type of Recipient Committee: All Committees - Complete Parts 1,2,3, and 4. <br />2. Type of Statement: <br />❑Officeholder, Candidate Controlled Committee ❑ Ballcit Measure Committee <br />❑ Pre - election Statement ❑ Quarterly Statement <br />0 State Candidate Election Committee 0 Primary Formed <br />0 Semi - annual Statement ❑ Special Odd -Year Report <br />0 Recall 0 Controlled <br />❑ Termination Statement ❑ Supplemental Preelection <br />(Also Complete Part 5.) 0 Sponsored <br />(Explain below) Statement -Attach Form 495 <br />❑❑Amendment <br />General Purpose Committee (Also Complete Part 6.) <br />0 Sponsored ❑ Primary Formed Candidate/ <br />0 Small Contributor Committee Officeholder Committee <br />0 Political Party /Central Committee (Also Complete Part 7.) <br />3. <br />Committee Information I.D.NUMBER <br />1256312 <br />Treasurer(s) <br />COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE <br />NAME OF TREASURER <br />Mike Gardner for City Council 2011 <br />Kathleen Daley <br />STREET ADDRESS NO P.O. BOX) <br />MAILING ADDRES <br />CITY STATE <br />CITY STATE ZIP CODE AREA CODE/PHONE <br />Riverside CA <br />Riverside CA <br />MAI N D ERENT) NO. AND STREET OR P.O. BOX <br />NAME OF ASSISTANT TREASURER, IF ANY <br />MAILING ADDRESS <br />CITY STATE ZIP CODE AREA CODE /PHONE <br />Riverside CA - <br />- IL ADDRESS <br />CITY STATE ZIP CODE AREA CODE/PHONE <br />OPTIONAL: FAX/E -MAIL ADDRESS <br />4. <br />Verification <br />I have used all reasonable diligence in preparing and reviewing this statement and to the <br />best of my knowledge the information contained herein and in the attached schedules <br />is true and complete. I certify under penalty of perjury under the laws of the St of Califo ' th fore oing is true and correct. <br />Executed on 01/21/2010 By Kathleen Dale <br />DATE SIGNATU <br />Executed on 01/21/2010 By Mike Gardner <br />DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDA , STATE MEASURE PROPONENT OR RESPONSIBLE OFFICER OF SPONSOR <br />Executed on By <br />DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, <br />CANDIDATE, STATE MEASURE PROPONENT <br />Executed on By <br />FPPC Form 460 (January /05) <br />DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, <br />CANDIDATE, STATE MEASURE PROPONENT FPPC Toll -Free Helpline: 866 /ASK -FPPC <br />State of California <br />