Kearney 470Officeholder and Candidate
Campai Statement
Short Form
(Government Code Section 84206)
T or print in ink.
Date of election if applicable: Amendment (Explain Below
(Month, Da Year
Date Stamp
u L
SHORT FORM
WN. h 6� Fr Use Onl
QT-
'TV7
Statement Covers Calendar Year _20 (20i K1 0FRCE
67
2. Officeholder or.Candidate Information 3. off ice Sau ht or Held
CIF NAVE OF OFF CEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
STRVE DQRE JURISDICTION (LOCAYION
fr
CITY
�4
STATE ZIP CODE
AREA QODE/DAYTIME PH E OPTIONAL' FAX E-KklL,,4bDRESS
t7
4. Committee Information
List all cornmittees of which y ou have knowled that are primaril formed to recel've contributions or to make expenditures on behalf cf candidac
COMMITTEE NAME AND I.D. NUMBER I COMMITTEE ADDRESS I NAmF- nF TRPA5�11RFR
5. Verification
DISTRICT NUMBER
(IF APPLICABLE)
I declare under penalt of per that to the best of m knowled I anticipate that I will receive less than $1 and that I will spend less than $1 000 durin the
calendar y ear and that I have Used all reasonable dili in preparin this statement, I certif Linder penalt per Linder the laws of the S of California that the fore is tr and correct, �o
ExeCLIted on
B y
DATE
SIGNATURE -OPOFFICEHOLDER OR CANDIDATE
FPPC Form 4701470 Supplement (Januar
FPPG Toll-Free Helpfine: 866/ASK-FPPC (866/275-3772)