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Recipient Committee <br />Campaign Statement <br />(Government Code Sections 84200 - 84216.5) <br />Type or print in ink. <br />Statement covers period <br />from 01/01/2013 <br />SEE INSTRUCTIONS ON REVERSE I through 04/20/2013 <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 />0 State Candidate Election Committee 0 Primary Formed <br />0 Recall 0 Controlled <br />(Also Complete Part 5.) 0 Sponsored <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. Committee Information 1 1 13555 1 <br />1355581 <br />COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE <br />Mike Soubirous for Riverside City Council - Ward <br />3, 2013 <br />STREET ADDRESS N P OX) <br />CITY STATE ZIP CODE AREA CODE PH <br />Riverside CA <br />MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX <br />CITY STATE ZIP CODE AREA CODE/PHONE <br />OPTIONAL: FAX/E -MAIL ADDRESS <br />4. Verification <br />I have used all reasonable diligence i <br />is true and complete. I certify under <br />Executed on � " 2 3 —.2 0 13 <br />DATE <br />Executed on 4 121_2443 <br />DATE <br />Executed on By <br />DATE <br />Executed on By <br />DATE <br />COVER PAGE <br />Date Stamp CALIFORNIA <br />RECEIVED FORM 460p <br />Date of election if applicable: APR 2 5 2013 1/12 <br />(Month, Day, Year) For Official Use Only <br />City of Riverside <br />06/04/2013 City Clerk's Office <br />2. Type of Statement: <br />0 Pre - election Statement ❑ Quarterly Statement <br />❑ 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 />Mrs. Dana Hopkins, CPA <br />MAILING ADDRESS <br />CITY STATE ZIP CODE AREA CODE/PHONE <br />Riverside CA <br />NAME OF ASSISTANT TREASURER, IF ANY <br />MAILING ADDRESS <br />CITY STATE ZIP CODE AREA CODE /PHONE <br />d to the best of my knowledge the information contained herein and in the attached schedules <br />I of California that the foregoing is true and correct. <br />TE, STATE MEASURE PROPONENT OR RESPONSIBLE OFFICER OF SPONSOR <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 />