HomeMy Public PortalAboutForm 470 (2)Officeholder and Candidate
Campaign Statement -
Short Form
(Government Code Section 84206)
1. Statement Covers Calendar Year 20
Type or print In Ink
Date of election If applicable: ~ Amendment (Explain Below)
(Month, Day, Year)
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COMMITTEE ADDRESS
SHORT FORM
For OftiClal Use Only
2. Officeholder or Candidate Information 3. Office Sought or Held
NAME OF OFFICEHOLDER OR CANDIDATE OFFICE SOUGHT OR HELD
STREETADDRESS
CITY STATE ZIP CODE
AREA CODE/DAYTIME PHONE NUMBER ' OPTIONAL: FAX / E-MAIL ADDRESS
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JURISDICTION (LOCATION)
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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
Date Stamp
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J U ~. 3 1 20171
C17Y CLERK
CITY OF CLAREMONT
NAME OF TREASURER
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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 perjury under the laws of the State of
California that the foregoing is true and correct.
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Executed on ~~~ / /0 ~ By ~
DATE SIGNATURE OF OFFICEHOLDER OR CANDIDATE
FPPC Form 450 (June/01)
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