Kearney 470Officeholder and Candidate
Campaign Statement -
Short Form
Type or print in ink.
(Government Code Section 84206) Date of election if applicable: O Amendment (Explain Below)
(Month, Day, Year)
} , J-D2--r-z_::,1~ o~ 1. Statement Covers Calendar Year 20 __ •
2. Officeholder or Candidate Information 3. Office Sought or Held
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD srnEbA~! fl/ fL. j{~AYLNf'/ 4ttJJ J oYL.
JURISDICTION (LOCATION)
c.1 or:
CITY
~~AMEJ)A. ~A C/,'f;Jo)
OPTIONAL: FAX I E-MAIL ADDRESS
4. Committee Information
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 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 fore oing is rue and correct. /
L /-~ ~
Executed on BY-----------'""'-------->.----------
FPPC Form 450 (June/01)