Form 470Officeholder and Candidate
Campaign Statement -
Short Form
Date of election if applicable: I ElAmendment (Explain Below)
(Month, Day, Year)
t>'/ Lrz-
1. Statement Covers Calendar Year 20
2-
Date Stamp
ITY OF: ENCiNJA
CITY CLERK
2. Officeholder or Candidate Information 3. Office Sought or Held
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
STREETADDRESS
CITY STATE ZIP CODE
"'Zoz 6f
AREA CODE/DAYTIME PHONE NUMBER OPTIONAL: FAX/ E-MAIL ADDRESS
exit -
JURISDICTION (LOC{
c' e-'f -1 d F �- u v
For
(IFAPPLICABLE)
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
5. Verification
COMMITTEE ADDRESS
NAME OF TREASURER
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 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.
Executed on
DATE
By
SIGNATURE OF OFFICEHOLDER OR CANDIDATE
FPPC Form 4701470 Supplement (Jan/2016)
FPPC Advice: advice@fppc.ca.gov (866/275-37;72)
www.fppc.ca.gov