470 fficeholder and Candidate
Campaign Statement-
Short Form
(Govemmenl Code Section 84206)
Type or print in ink.
Date ofelecUon if applicable: [] Amendment (ExpIEin Below)
(Month, Day, Year)
JUL ~ 3 ~001
SHORT FORM
For C)~m::lal Use Only
Statement Covers Calendar Year 20 ~l .
Officeholder or Candidate Information
NAME OF OFFICEHOLDER OR CANDIDATE
STREETADDRESS
Committee Information
STATE ZIP CODE
OPIIONA[: F,a0~ / E-~lL ADDRESS
3. Office Sought or Held
NAME OF TREASURER
OFFICE SOUGHT OR HELD
JURISDICTION (LOCATION)
JDISTRICT NUMBER
(IF APPLICABLE)
I declare under penalty of perjury that to the best of my knowledge I anticipate that I will receive less than $1,000 and that I will spend less than $1,000 during
the calendar year and that I have used all reasonable diligence in preparing this statement. I certify under penalty of perjury under the laws of the State of
Executed onCalif°rnia thatTthe/~.~foregoingfo, is true and correct. BY~'~~/~-- .~ ~ .
DATE SIGNATURE OF OFFICEHOLDER OR CANDIDATE
Form 470~470 SupplemEnt (t 2/99)
For Technical Assistance: 916/322-5660
State of California
5. Verification
List all committees of which you have knowledge that are primarily formed to receive contributions or to make expenditures on behalf of your candidacy.
COMMrrrEE NAME AND I.D. NUMBER COMMI'I-FEE ADDRESS