HomeMy Public PortalAboutForm 470Officeholder and Candidate
Campaign Statement -
Short Form
(Government Code Section 84206)
1. Statement Covers Calendar Year 20 ~_ .
For Ofnclal Use
FORM
2. Officeholder or Candidate Information 3. Office Sought or Held
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
STREET ADDRESS JURISDICTION (LOCATION) DISTRICT NUMBER
// n~ y (IF APPLICABLE)
~~1 ~ ~b~L/~~"~ C~~4~~ l _
CITY STATE ZIP CODE
c y r~ ,~~ n ~~ ~ Cf ~ ~ t ` f~
AREA CODE/DAYTIME PHONE NUMBER OPTIONAL: FAX I EMAIL ADDRESS
Type or print In Ink.
Date of election if applicable: ~ Amendment (Explain Below)
(Month, Day, Year)
RECI~~~'ED
JAN 2 5 2001
CITY CLERK
GTtl OF CLAREMONT
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
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 p ry under the laws of the State of
California that the foregoing is true and correct. ~
~~y~ ~~~, ~ C~cQ ~ By ~~L_
Executed on
DATE SIGNATURE OF OFFICEHOLDER OR CANDIDATE
Forth 4701470 Supplement (12199)
For Technical Assistance: 9161322-5560
State of California