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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 <br />m <br />07/01/2011 <br />SEE INSTRUCTIONS ON REVERSE <br />through 12/31/2011 <br />1. Type of Recipient Committee: All Committees - Complete Parts 1,2,3, and 4. <br />X❑ Officeholder, Candidate Controlled Committee ❑ Ballot Measure Committee <br />Q State Candidate Election Committee Q Primary Formed <br />Q Recall Q Controlled <br />(Also Complete Part 5.) Q Sponsored <br />❑ General Purpose Committee (Also Complete Part 6.) <br />Q Sponsored ❑ Primary Formed Candidate/ <br />Q Small Contributor Committee Officeholder Committee <br />Q Political Party /Central Committee (Also Complete Part 7.) <br />3. Committee Information <br />I.D.NUMBER <br />1256312 2 <br />COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE <br />Mike Gardner for City Council 2011 <br />STREET ADDRESS NO P.O. BOX <br />CITY STATE <br />Riverside CA <br />4. <br />MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX <br />COVER PAGE <br />EC VED 1 2FORM2.A 400 <br />1 / 9 <br />Date of election if applicable: JAN 2 3 2012 <br />(Month, Day, Year) City f Riverside <br />y For Official Use Only <br />City Clerk's Office <br />06/07/2011 <br />2. Type of Statement: <br />❑ Pre - election Statement ❑ Quarterly Statement <br />X❑ Semi - annual Statement ❑ Special Odd -Year Report <br />❑ Termination Statement ❑ Supplemental Preelection <br />❑ Amendment (Explain below) Statement - Attach Form 495 <br />Treasurer(s) <br />NAME OF TREASURER <br />Richard Teaman <br />MAILING ADDRESS <br />CITY STATE ZIP CODE AREA CODE /PHONE <br />Riverside CA <br />NAME OF ASSISTANT TREASURER, IF ANY <br />Javier Carrillo <br />CITY STATE ZIP CODE AREA CODE /PHONE MAILING ADDRESS <br />' - AIL ADDRESS <br />Verification <br />CITY STATE ZIP CO <br />Riverside CA <br />OPTIONAL: FAX/E -MAIL ADDRESS <br />I have used all reasonable diligence in preparing and reviewing this statement and to the 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 rue and correct. <br />Executed on 01/13/2012 By Richard Teaman <br />DATE SIGNATUR - <br />Executed on 01/13/2012 By Mike Gardner <br />DATE SIGNATURE OF CONTROLLING OFFICEHOL SIBLE OFFICER OF SPONSOR <br />Executed on <br />DATE <br />Executed on <br />DATE <br />By <br />By <br />SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, STATE MEASURE PROPONENT <br />SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, STATE MEASURE PROPONENT <br />FPPC Form 460 (JAN /05) <br />FPPC Toll -Free Helpline: 866 /ASK -FPPC <br />State of California <br />