Form 470Officeholder and Candidate
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Type or print In ink.
Campaign Statement —
Short Form
(Government Code Section 84206) Date of election if applicable: Amendment (Explain Below )
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For Official Use Only
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1. Statement Covers Calendar Year 20 12- .
2. Officeholder or Candidate Information 3. Office Sought or Held
NAME OFF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD /
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STREET ADDRESS JURISDICTION (LOCATION) DISTRICT NUMBER
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CITY ' STATE ZIP CODE
AREA CODE /DAYTIME PHONE NUMBER OPTIONAL. FAX/ E -MAIL ADDRESS
76o- ?OY- 2S'08 -lt�ybiropAy@g Pi, a;1 , cow
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 I COMMITTEE AD
5. Verification
NAME OF TREASURER
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.
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Executed on - -- -- By
DATE SIGNATURE OF OFFICEHOLDER OR CA DIDATE
FPPC Form 470/470 Supplement (January/08)
FPPC Toll -Free Helpline: 866 1ASK -FPPC (866/276 -3772)