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IPrint Form <br />Officeholder and Candidate <br />Campaign Statement - <br />Short Form <br />Date of election if applicable: <br />(Month, Day, Year) <br />/4(72,0/5 <br />1. Statement Covers Calendar Year 20 1 <br />Amendment (Explain Below) <br />Date Stamp <br />HECEIVED <br />FEB 11 2019 <br />City of Riverside <br />Vit,/ ''Ifiglawgiike <br />2. Officeholder or Candidate Information 3. Office Sought or Held <br />NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD <br />A/IT-sKlr-ts- <br />STREET ADDRESS <br />CITY <br />iret- <br />STATE TIP COD <br />AREA CODE/DAYTIME PHONE NUMBER OPTIONAL. FAX / E-MAIL ADDRESS <br />CALIFORNIA 470 <br />FORM <br />For Official Use Only <br />g1/0 rd z-/777 C4uA t� <br />JURISDICTION (LOCATION) DISTRICT NUMBE <br />{:F APPLICABLE) <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 I D NUMBER COMMITTEE ADDRESS NAME OF TREASURER <br />//t <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 I 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 />Executed on <br />Clear Form <br />71( MTE <br />By <br />A <br />J .SIGNATURE OF OFFICEHOLDER 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 />