Appezzato 470Officeholder and Candidate
Campaign Statement -
Short Form
Type or print in ink.
(Government Code Section 84206) Date of election if applicable: D Amendment (Explain Below)
(Month, Da , Year)
2. Officeholder or Candidate Information
NAME OF OFFICEHOLDER OR CANDIDATE /<~l1·
4. Committee Information
3. Office Sought or Held
JURISDICTION 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.
COMMITIEE NAME AND l.D. NUMBER COMMITIEE ADDRESS NAME OF TREASURER
5. Verification
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
California that the foregoi g is ue and correct.
FPPC Form 450 (June/01)
FPPC Toll-Free Helpline: 866/ASK-FPPC