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Recipient Committee <br />Campaign Statement <br />Cover Page <br />(Government Code Sections 84200- 84216.5) <br />SEE INSTRUCTIONS ON REVERSE <br />Type or print in ink. <br />Statement covers period <br />6,lvt3) 1 za <br />1 � <br />through �- 3 - <br />from <br />Date of election if applicable: <br />(Month, Day, Year) <br />REdWWED <br />JAN 10 2013 <br />OFFICE OF THE <br />CITY CLERK <br />COVER PAGE <br />For Official Use Only <br />1. Ty <br />of Recipient Committee: All Committees— Complete Parts 1, 2, 3, and 4. <br />Officeholder, Candidate Controlled Committee <br />Q State Candidate Election Committee <br />Q Recall <br />(Also Complete Part 5) <br />p General Purpose Committee <br />Q Sponsored <br />Q Small Contributor Committee <br />O Political Party /Central Committee <br />❑ Primarily Formed Ballot Measure <br />Committee <br />Q Controlled <br />Q Sponsored <br />(Also Complete Part 6) <br />❑ Primarily Formed Candidate/ <br />Officeholder Committee <br />(Also Complete Part 7) <br />2. Type of Statement: <br />❑ Preelection Statement <br />[/ Semi - annual Statement <br />❑ Termination Statement <br />(Also file a Form 410 Termination) <br />❑ Amendment (Explain below) <br />❑ Quarterly Statement <br />❑ Special Odd -Year Report <br />❑ Supplemental Preelection <br />Statement - Attach Form 495 <br />3. Committee information <br />I.D. NUMBER <br />6� <br />COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) <br />CITY STATE <br />ZIP CODE AREA CODE /PHONE <br />OPTIONAL: FAX / E -MAIL ADDRESS <br />Treasurer(s) <br />NAME OF TREASURER <br />a\ ��rsN SarcL <br />IP CODE <br />AREA CODE /PHONE <br />MAILING ADDRESS <br />CITY <br />STATE ZIP CODE <br />AREA CODE /PHONE <br />OPTIONAL: FAX l E -MAIL ADDRESS <br />4. Verification <br />have used all reasonable diligence in preparing and reviewing this statement and to th <br />under penalty of perjury uryder tie laws of the State of California that the foregoing is true <br />is true and complete. I certify <br />Executed on <br />Executed on <br />Executed on <br />Executed on <br />l <br />Date <br />Date <br />Dale <br />By <br />By <br />By <br />By <br />Signature of Cmtroiling Officeholder, Candldale, State Measure Proponent <br />FPPC Form 460 (January/05) <br />FPPC Toll -Free Helpline: 866/ASK -FPPC (866/275 -3772) <br />State of California <br />