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Kennedy 470Officeholder and Candidate Campaign Statement - Short Form (Government Code Section 84206) Type or print in ink. Date of election if applicable: D Amendment (Explain Below) (Month, Day, Year) 1. Statement Covers Calendar Year 20 ___ _ 2. Officeholder or Candidate Information AREA CODE/DAYTIME PHONE NUMBER 4. Committee Information STATE ZIP CODE OPTIONAL: FAX I E-MAIL ADDRESS 3. Office Sought or Held OFFICE SOUGHT OR HELD DISTRICT NUMBER (IF APPLICABLE) List all committees of which you have knowledge that are primarily formed to receive contributions or to make expenditures on behalf of your candidacy. COMMITTEE NAME AND l.D. NUMBER COMMITTEE ADDRESS NAME OF TREASURER 5. Verification I declare under penalty of perjury that to the best of my knowledge I anticipate that I will receiye 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.1~.<1ertify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. ~~/ Executed FPPC Form 450 (June/01) FPPC Toll-Free Helpline: 866/ASK-FPPC Officeholder and Candidate Campaign Statement form 470 Supplement (Government Code Section 84206) SEE INSTRUCTIONS ON REVERSE Type or print in ink. 0 Amendment (Explain Below) This form is written notification that the officeholder/candidate listed below has received contributions totaling $1,000 or more or has made expenditures of $1,000 or more during the calendar year. 1. Officeholder or Candidate Information STREET ADDRESS CllY AREA CODE/DAYTIME PHONE NUMBER 2. Office Sought OFFICE SOUGHT STATE ZIP CODE OPTIONAL: FAX I E-MAIL ADDRESS DISTRICT NUMBER (IF APPLICABLE) FORM 470 SUPPLEMENT Date Stamp CALIFORNIA 470 FORM SUPPLEMENT For Official Use Only 3. Date Contributions Totaling $1,000 or More Were Received or Date Expenditures of $1,000 or More Were Made (MONTH, DAY, YEAR) FPPC Form 450 (June/01) FPPC Toll·Free Helpline: 866/ASK·FPPC