Kearney 470Officeholder and Candidate
Campaign Statement -
hort Form
(Government.Code Section 84206)
Type or print in ink„
Cate of electi on if applicable. (� �mendl�lei"1t {E(plain Below)
(Month, Day, Year)
Date Stamp:
SHORT FORM
For Official Use Only
I N Statement Covers Calendar Year 20
5.. Verification
declare under penalty of perjury that to the best of my knowledge I anticipate that I will receive less than $1,000 and that 1 will s ss than $1,000 during the
calendar year and that l have used all reasonable diligence in preparing this statement. I certify under the State of California
that the foregoing is true ang Corr t.
Executed on B
MATE SIGNATURE OF OFFICEHOI.
FPPC Form 4701470 Supplement (January108)
FPPC Toll -Free Helpline: 8861AS.K -FPPC (8661275- 3772)
R OR CANDIDATE