HomeMy Public PortalAboutForm 470 (3)Officeholder and Candidate
Campaign Statement -
Short Form
(Government Code Section 84206)
Type or print In ink.
Date ofelectlonlfappllcable: I ~ Am@ndment (Explain Below)
(Month, Day, Year)
l P~ G~ c.l
Date Stamp
RECEIVED
JUL~02001
CITY CLERK
CITY OF CI.AREMONT
SHORT FORM
1. Statement Covers Calendar Year 20 ~~ .
2. Officeholder or Candidate Information 3. Office Sought or Held
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
STREET ADDRESS
CITY STATE ZIP CODE
AREA CODE/DAYTIME PHONE NUMBER OPTIONAL: FAX / E-MAIL ADDRESS
For
JURISDICTION (LOCATION) DISTRICT NUMBER
G ` ~~ M ~~ ~ (IF APPLICABLE)
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 $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 erjury under the laws of the State of
California that the foregoing is true and correct.
Executed on ` ~ By
DATE SIGNATURE OF OFFICEHOLDER OR CANDIDATE
Forrn 470/470 Supplement (12/99)
For Technical Assistance: 9161322-5660
State of California