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Form 470 Short Form roll, Off ceholder and Candidate Date stamp • WOfficialUse Campaign Statemen t- -Y Ol: E ICII~IMTA • -Short Form Date of election if applicable: ❑ Amendment (ExplainBeiow) CITY CLERK For y (Month,Day,Year) WE AU -g AM 1[: 319 1. Statement Covers Calendar Year 20 i 2. Officeholder or Candidate Information 3. Office Sought or Held NAME OF OFFICEHOLDER OR CANDIDATE / OFFICE SOUGHT OR HELD 5 71 t AREA CODEIDAYTIME PHONE NUMBER OPTIONAL- FAX l E-MAILADDRESS w t . 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 COMMITTEE ADDRESS NAME OF TREASURER I. i i i, 5. Verifi cation - I declare under penalty of perjury that to the best of my knowledge I anticipate that I will receive less than$2,000 and that I will spend less than$2,000"during the calendar y and that I have I' used all reasonable diligence in'.preparing this state me t. I certify under penalty of perjury under the laws of the Stat of Califor ' a e re In a orrec. V �r9 - 2,2 1, { Executed on © `� By- DATE SIGNATURE OF OFFIC DER OR CANDIDATE fnor lit InOFri1 FPPC Form 470/470 Supplement(Jan 12016) FPPC Advice: advice @fppc.ca.gov(866/275-3772) { www.fppc.ca.gov