HomeMy Public PortalAboutForm 470 (2)Officeholder and Candidate
Campaign Statement -
Short Form
(Government Code Section 84206)
Type or print In Ink.
Dace ofelectlon If applicable: I ~ Amendment (Explain Below)
(Month, Day, Year)
SHORT FORM
For O(ficlal Use Only
1. Statement Covers Calendar Year 20 = r~
2. Officeholder or Candidate Information 3. Office Sought or Held
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
STREET ADDRESS ~~/r- C~/ ~'fd~
CITY STATE ZIP CODE
OPTIONAL:
/E-
~. r.O GA /i~' G J ~ ~ y.=~ ~ Y- y~
JURISDICTION (LOCATION) DISTRICT NUMB
~ ~ (IFAPPLICABLE)
4. Committee Information
(_ist 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
Date Stamp
RECEIVED
FEB 2 3 2001
CITY OFF CLAREMONT
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 certify under pe Ity of perjury under the laws of the State of
California that the foregoing is true and correct.
Executed on ~~ ,-- ~ ~ - ~ ~ By
DATE SIGNATURE OF OFFICEHOLDER OR CANDIDATE
Form 4701470 Supplement (12/99)
For Technical Assistance: 916/322-5660
State of Callfornla