Elefant 470Officeholder and Candidate
Campaign Statement -
Short Form
Type or print in ink.
(Government Code Section 84206) Date of election if applicable: D Amendment (Explain Belo
(Month, Day, Year)
1. Statement Covers Calendar Year 20 ~-
2. Officeholder or Candidate Information
NAME OF OFFICEHOLDER OR CANDIDATE
STREET ADDRESS
4. Committee Information
3. Office Sought or Held
OFFICE SOUGHT OR HELD
SHORT FORM
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 1.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 foregoing is true and correct.
DATE
By_
FPPC Form 450 (June/01)
FPPC Toll-Free Helpline: 866/ASK-FPPC