470 fficeholder and Candidate ~, SHORT FORM
Campaign Statement - lypeor print In Ink. 470
FORM
Short Form EOEIVE
(Government Code Section 84~6) Dateofele~tlonlfappllcable: [] Amendment (ExplalnBelow) ~' For Ollk:bl Use Only
(Monlh, Day, Year)
JUL ~ 4
r"ITY OF CUPI:PT NC)
1. Statement Covers Calendar Year 20 ~ ~..
2. Officeholder or Candidate Information 3. Office Sought or Held
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT O~HELD ~
STREET ADDRESS JURISDICTION (LOCATION) DISTRICT NUIdSER
CITY I STALE ZiP CODE
E NUMBER OPTIONAL: FAX / E-MAIL ADDRESS
4. Committee Information
Li, t all committees of which you have knowledge that are pr/madly formed to receive contributions or to make expenditures on behatt of your candidao/.
COMMITTEE NAME ~ID I.D. NUMBER COMMITrEE ADDRESS N~dE OF TREASURER
5. Verification
I
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
Ex--onCalif°mia that the foregoing is true and correct.7~ ,.--,,_~ z.~--(~)o,~E ~ By /~~~1~'~-~.' ~~SiGNATURE OF
FPPC Form 450 (June/O1)
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