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Officeholder and Candidate <br />/Campaign Statement - <br />Short Form <br />Date of election if applicable: <br />(Month, Day, Year) <br />0 Amendment (Explain Below) <br />RECEIVE <br />MAR 01 2019 <br />City of Riverside <br />City Clerk's Office <br />CALIFORNIA <br />FORM <br />For Official Use Only <br />1. Statement Covers Calendar Year 20 <br />2. Officeholder or Candidate Information <br />� <br />NAME <br />EOOF OFFICEHOLDER OR CANDIDATE <br />is,+v <br />STREET ADDRESS <br />CITY <br />AREA CODE/DAYTIME PHONE NUMBER <br />STATE <br />OPTIONAL: FAX / E-MAIL ADDRESS <br />3. Office Sought or Held <br />OFFICE SOUGHT OR HELD <br />C)\ -'q <br />JURISDICTIOATION <br />) <br />s2.\\ivsd' <br />DISTRICT NUMBER <br />(IPLICABLE) <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 . 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 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 />� �las1`1 <br />DATE <br />Print; Form <br />By <br />ATE <br />FPPC Form 470/470 Supplement (Jan/2016) <br />FPPC Advice: advice@fppc.ca.gov (866/275-3772) <br />www.fppc.ca.gov <br />