460 Soubirous (04-21-13 - 05-18-13) R

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Recipient Committee COVER PAGE Campaign Statement Type or print in ink. teStam RE FIVE CA2001/002(A 460 (Government Code Sections 84200 - 84216.5) FORM 1 / 11 MAY 2 3 2013 Statement covers period Date of election if applicable: from 04/21 /2013 (Month, Day, Year) City of Riverside For Official Use Only Y City Clerk's Office SEE INSTRUCTIONS ON REVERSE through 05/18/2013 06/04/2013 1. Type of Recipient Committee: All Committees - Complete Parts 1,2,3, and 4. 2. Type of Statement: ❑ Officeholder, Candidate Controlled Committee ❑ Ballot Measure Committee E Pre - election Statement ❑ Quarterly Statement Q State Candidate Election Committee Q Primary Formed ❑ Semi - annual Statement ❑ Special Odd -Year Report Q Recall Q Controlled ❑ Termination Statement ❑ Supplemental Preelection (Also Complete Part 5.) ❑ General Purpose Committee O Sponsored ❑Amendment (Explain below) Statement - Attach Form 495 (Also Complete Part 6.) Q Sponsored ❑ Primary Formed Candidate/ Q Small Contributor Committee Officeholder Committee Q Political Party /Central Committee (Also Complete Part 7.) 3. Committee Information 113555811ER Treasurer(s) COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE NAME OF TREASURER Mike Soubirous for Riverside City Council - Ward Mrs. Dana Hopkins, CPA 3, 2013 STREET ADDRESS NO P.O. BOX) MAILING ADDRESS CITY STATE ZIP CODE AREA CODE /PHONE CITY STATE ZIP CODE AREA CODE /PHONE Riverside CA - Riverside CA MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX NAME OF ASSISTANT TREASURER, IF ANY MAILING ADDRESS CITY STATE ZIP CODE AREA CODE /PHONE OPTIONAL: FAX/E -MAIL ADDRESS CITY STATE ZIP CODE AREA CODE /PHONE OPTIONAL: FAX/E -MAIL ADDRESS 4. Verification I have used all reasonable diligence i nd to the best of my knowledge the information contained herein and in the attached schedules is true and comple e. I certify under to of California that the foregoing is true and correct. Executed on 0 2 117— 0 13 B ds �� Zip t3 ASURER OR ASSISTANT TREASURER Executed on B DATE (DATE, STATE MEASURE PROPONENT OR RESPONSIBLE OFFICER OF SPONSOR Executed on By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, STATE MEASURE PROPONENT Executed on By FPPC Form 460 (JAN /05) DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, STATE MEASURE PROPONENT FPPC Toll -Free Helpline: 866 /ASK -FPPC State of California