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Recipient Committee <br />Campaign Statement <br />(Government Code Sections 84200 - 84216.5) <br />m <br />SEE INSTRUCTIONS ON REVERSE <br />fro <br />Type or print in ink. <br />Statement covers period I Date of election if applicable: <br />05/19/2013 (Month, Day, Year) <br />through 06/30/2013 <br />1. Type of Recipient Committee: All Committees - Complete Parts 1,2,3, and 4. <br />❑X Officeholder, Candidate Controlled Committee <br />❑ Ballot Measure Committee <br />Q State Candidate Election Committee <br />Q Primary Formed <br />Q Recall <br />Q Controlled <br />(Also Complete Part 5.) <br />O Sponsored <br />❑ General Purpose Committee <br />(Also Complete Part 6.) <br />Q Sponsored <br />❑ Primary Formed Candidate/ <br />Q Small Contributor Committee <br />Officeholder Committee <br />Q Political Party /Central Committee <br />(Also Complete Part 7.) <br />I.D.NUMBER <br />3. Committee Information 1355581 <br />COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE <br />Mike Soubirous for Riverside City Council - Ward <br />3, 2013 <br />0. BOX) <br />CITY STATE JE <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 in <br />is true and complete. I certify under pe <br />Executed on -7" ZS - By <br />TE <br />Executed on "7 — Z — 7-t, t3 By <br />DATE <br />Executed on <br />DATE <br />Executed on By <br />DATE <br />Date Stamp <br />ECEIVED <br />JUL 312013 <br />COVER PAGE <br />CALIFORNIA ��O <br />2001/02 <br />FORM <br />1/11 <br />For Official Use Only <br />City of Riverside <br />06/04/2013 City Clerk's Office <br />2. Type of Statement: <br />❑ Pre - election Statement ❑ Quarterly Statement <br />0 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 liff1iiijo AREA CODE /PHONE <br />Riverside CA <br />NAME OF ASSISTANT TREASURER, IF ANY <br />MAILING ADDRESS <br />CITY <br />OPTIONAL: FAX/E -MAIL ADDRESS <br />STATE ZIP CODE AREA CODE /PHONE <br />I the best of my knowledge the information contained herein and in the attached schedules <br />California that the foregoing is true and correct. <br />STATE MEASURE PROPONENT OR RESPONSIBLE OFFICER OF SPONSOR <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 105) <br />FPPC Toll -Free Helpline: 866 /ASK -FPPC <br />State of California <br />