HomeMy Public PortalAboutForm 470Officeholder and Candidate
Campaign Statement -
Short Form
(Government Code Section 84206)
Type or print In Ink.
Date of election If applicable:
(Month, Day, Year)
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1. Statement Covers Calendar Year 20 ~!
Dete Stamp
RECEIVED
For
JAN 2 6 2001
CITY CLERK
CITY OF CLAREMONT
SHORT FORM
2. Officeholder or Candidate Information 3. Office Sought or Held
ME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
f~~ ~~ ,~° i ~ ~~v ~ ~i ~ f~ ~i ~ ~ C~ ,tie ~~ i~lfrr,~~iz
STREET ADDRESS JURISDICTION (LOCATION) DISTRICT NUMBER
_ (IF APPLICABLE)
G~ ~ - i- ~ . JI/ Ji ~'I/l~ N~~ ~ /~.r/~ . C' . F~no~r/;r- C~.(J ~ ino~c% ~
n~TV CTATG TID !`/~f1C
AREA CODEIDAYTIME PHONE NUMBER OPTIONAL: FAX / E-MAIL ADDRESS
4. Committee Information
Lisf 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
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 rtify under,penalty of perjury un r the laws of the S
California that the foregoing is tr a and correct. (~ ` v~ y J
Executed on ~'- ~ ~ ~ By
DATE SIGNATURE OF OFFICEHOLDER OR CANDIDATE
Form 4701470 Supplement (12199)
ForTechnlcal Assistance: 9161322-5880
State of California