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Recipient Committee <br />COVER PAGE <br />Campaign Statement <br />Type or print in ink. Date Stamp CALIFORNIA <br />2oo�io2 460 <br />(Government Code Sections 84200 - 84216.5) <br />EC E IVE ® FORM <br />Statement covers period Date of election if applicable: 1/17 <br />Day, OCT 2 2 2013 <br />from 09/22/2013 (Month, Year) <br />For Official Use Only <br />City of Riverside <br />SEE INSTRUCTIONS ON REVERSE <br />through 10/19/2013 11/05/2013 City Clerks Office <br />1. Type of Recipient Committee: All Committees - Complete Parts 1,2,3, and 4. 2. Type of Statement: <br />❑X Officeholder, Candidate Controlled Committee <br />❑ Ballot Measure Committee -election Statement El Quarterly Statement <br />El <br />O State Candidate Election Committee <br />Q Primary Formed <br />Recall <br />Q Controlled E] Semi-annual Statement ❑ Special Odd -Year Report <br />(Also Complete Part 5.) <br />Q Sponsored El Termination Termination Statement Supplemental Preelection <br />❑ General Purpose Committee <br />E] Amendment (Explain below) Statement - Attach Form 495 <br />O Sponsored <br />(Also Complete Part 6.) <br />Q Small Contributor Committee <br />❑ Primary Formed Candidate/ <br />Officeholder Committee <br />Q Political Party /Central Committee <br />(Also Complete Part 7.) <br />3. Committee Information <br />I.D.NUMBER <br />1355581 Treasurer(s) <br />COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE NAME OF TREASURER <br />Mike Soubirous for Riverside City Council - Ward <br />3, 2013 <br />Mrs. Dana Hopkins, CPA <br />STREET ADDRESS (NO P.O. BOX) <br />MAILING ADDRESS <br />CITY STATE ZIP CODE AREA CODE /PHONE CITY STATE ZIP CODE AREA CODE /PHONE <br />Riverside CA Riverside CA — <br />MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX NAME OF ASSISTANT TREASURER, IF ANY <br />CITY STATE ZIP CODE AREA CODE /PHONE MAILING ADDRESS <br />OPTIONAL: FAX/E -MAIL ADDRESS <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 />d to the best of my knowledge the information contained herein and in the attached schedules <br />is true and complete. I certify under pe <br />of California that the foregoing is true and correct. <br />Executed on (d r 2 L z 0 13 By <br />DATE <br />Executed Z — ZCYJ <br />URER OR ASSISTANT TREASURER <br />on By <br />DATE <br />1111.11111,11IN ATE, STATE MEASURE PROPONENT OR RESPONSIBLE OFFICER OF SPONSOR <br />Executed on By <br />DATE <br />SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, STATE MEASURE PROPONENT <br />Executed on By <br />FPPC Form 460 (JAN 105) <br />DATE <br />SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, STATE MEASURE PROPONENT FPPC Toll -Free Helpline: 866 /ASK -FPPC <br />State of California <br />