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Recipient Committee <br />Campaign Statement <br />Cover Page <br />SEE INSTRUCTIONS ON REVERSE <br />Statement covers period <br />from <br />through <br />1. Type of Recipient Committee: All Committees - Complete Parts 1, 2, 3, and 4. <br />Yq" O iiceholder, Candidate Controlled Committee ❑ Primarily Formed Ballot Measure <br />O State Candidate Election Committee Committee <br />O Recall 0 Controlled <br />(Also Complete Part 5) 0 Sponsored <br />(Also Complete Part 6) <br />❑ General Purpose Committee <br />0 Sponsored <br />0 Small Contributor Committee <br />0 Political Party/Central Committee <br />3. Committee Information <br />❑ Primarily Formed Candidate/ <br />Officeholder Committee <br />(Also Complete Part 7) <br />C MMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) <br />CITY STATE ZIP CODE AREACODE/PHONE <br />OPTIONAL: FAX/E-MAILADDRESS <br />4. Verification <br />I have used all reasonable diligence in preparing and reviewing this statement and <br />certify under penalty of perjury <br />un er the laws of the State of California that the fore <br />Executed on C By <br />Datb <br />41 <br />Executed on By <br />Date <br />Executed on <br />Date <br />Executed on <br />Date <br />Date of election if applicable: <br />(Month, Day, Year) <br />COVER PAGE <br />SEP 2 0 2019 1 Page d of <br />City of Rive <br />u N Cid Clerk's <br />2. Tyf Statement: <br />Preelection Statement <br />❑ Semi-annual Statement <br />❑ Termination Statement <br />(Also Ile a Form 410 Termination) <br />mendment (Explain below) y <br />Treasurer(s) <br />For Official Use Only <br />❑ Quarterly Statement <br />❑ Special Odd -Year Report <br />MAILING ADDRESS <br />CITY STATE ZIP CODE AREA CODE/PHONE <br />OPTIONAL: FAX/E-MAIL ADDRESS <br />By <br />Signature of Controlling Officeholder, Candidate, State Measure Proponent <br />By <br />Signature of Controlling Officeholder, Candidate, State Measure Proponent <br />is true and complete. I <br />FPPC Form 460 (Jan/2016) <br />FPPC Advice: (866/275-3772) <br /> <br />