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Officeholder and Candidate <br />Campaign Statement - <br />Short Form <br />CALIFORNIA70' <br />FORM <br />Date of election if applicable: <br />(Month, Day, Year) <br />Amendment (Explain Below) <br />For Official Use Only <br />1. Statement Covers Calendar Year 20 <br />2. Officeholder or Candidate Information <br />NAME OF OFFICEHOLDER OR CANDIDATE <br />lt-&OC%(C� / I povGivw <br />CITY !� STATE <br />C r <br />ZIP CODE <br />3. Office Sought or Held <br />OFFICE SOUGHT OR HELD <br />l cs I / n/Cit, AIM/ <br />JURISDICTION (LOCATION) <br />cirri of.= Rc Ve-rs d <br />DISTRICT NUMBER <br />j)F APPLICABLE) <br />AREA CODE/DAYTIME PHONE NUMBER <br />OPTIONAL -FAX 1 E -MAL ADDRESS % <br />4. Committee Information <br />List all committees of which you have knowledge that are primarily formed to receive contributions or to make expenditures on behalf of your candidacy. <br />COMMITTEE NAME AND LD NUMBER COMMITTEE ADDRESS NAME OF TREASURER <br />5. Verification <br />I declare under penalty of perjury that to the best of my knowledge I anticipate that I will receive less than $2 ,000 and that I will spend less than $2,000 during the calendar year and that 1 have <br />used all reasonable diligence in preparing this statement. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. <br />/ig/3Io( <br />q <br />1 <br />Executed on <br />DATE <br />rintForm <br />By <br />SIGNATURE OF OFF I HOLDER OR CANDIDATE <br />FPPC Form 470/470 Supplement (Jan/2016) <br />FPPC Advice: advice@fppc.ca.gov (866/275-3772) <br />www.fppc.ca.gov <br />