Form 470 Candidate statement Officeholder and Candidate SHORT FORM
Campaign Statement— Type or print In ink. CIT Y t C. CALIFORNIA AM,
Short Form !. t p ' '
(Government Code Section 84206) Date of election If applicable: El Amendment (Explain Below2014 AUG 1 2 AM 10* For Official Use Only
(Month,Day,Year)
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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
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STREET ADDRESS JURISDICTION(LOCATION) DISTRICT NUMBER
ZIP CODE
AREA CODE/DAYTIME PHONE NUMBER OPTIONAL. FAX/E-MAIL ADDRESS
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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 1.0 NUMBER COMMITTEE ADDRESS NAME OF TREASURER
100 v`i..
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 erju under the I ws of the State of California
that the foregoing is true and correct.
Executed on , By ��
DATE SIG F OFFIC LDER OR CANDIDATE
FPPC Form 4701470 Supplement (January/08)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/276-3772)