Kearney 470Officeholder and Candidate
Campaign Statement -
Short Form
1.72
1. Statement Covers Calendar Year 20
Date of elect-ion if applicable: Amendment (Explain Below)
(Month, Day, Year)
2. Officeholder or Candidate Information
NAME OF OFFICEHOLDER OR CANDIDATE
) t.:A/11'
STREET.ADDRESS
ch
AREA CODE/DAYTIME PHONE NUMBER
SISSIMISMIL
STATE,
/ZI5CODE
- 7
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OPTIONAL: FAX %E-MAIL ADDRESS
3. Office Sought or Held
OFFICE SOUGHT OR HELD
4/1))
JURISDICTION (LOCATION)
Date Sta
JFOA
FORi
For Official Use It'
27 2015
CITY OF ALAMEDA
C177.
DISTRICT NUMBER
)4;â– PPLICABLE)
4. Committee Information
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 I.D. NUMBER COMMITTEE ADDRESS NAME OF TREASURER
7810M0.1
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 inpreparing thise§tatement. I certify under penalty of perjury under the laws
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Executed on / .(_. z , )
FPPC Form 470/470 Supplement Instructions - Rev. 2 (Dec/2012)
/ DATE By
If SIGNATURE ( ,
OF OFFICEHOLDER OR CANDIDATE
FPPC Form 470/470 Supplement (Jan/2008)
Clear Form Print Form FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
Officeholder and Candidate
Campaign Statement -
Form 470 Supplement
SEE INSTRUCTIONS ON REVERSE
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
NAME OF OFFICEHOLDER OR CANDIDATE
STREET ADDRESS
CITY STATE ZIP CODE
AREA CODE/DAYTIME PHONE NUMBER OPTIONAL: FAX / E-MAIL ADDRESS
2. Office Sought
OFFICE SOUGHT
DATE OF ELECTION (MONTH, DAY, YEAR)
DISTRICT NUMBER
(IF APPLICABLE)
Date Stamp
3. Date Contributions Totaling $1,000 or More Were Received or Date Expenditures of $1,000 or More Were Made
(MONTH, DAY, YEAR)
Clear Form
Print Form
CALIFORNIA 470
FORM
For Official Use Only
FPPC Form 470/470 Supplement (Jan/2008)
FPPC Form 470/470 Supplement Instructions - Rev. 2 (Dec/2012)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov