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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