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Recipient Committee <br />Campaign Statement <br />Cover Page <br />SEE INSTRUCTIONS ON REVERSE <br />Statement covers period <br />from 9-25— 2016 <br />through <br />1. Type of Recipient Committee: All committees — Complete Parts 1, 2, 3, and 4. <br />❑x Officeholder, Candidate Controlled <br />Committ® <br />Q State Candidate Election Committee <br />Recall <br />(Also Complete Part 5) <br />❑ General Purpose Committee <br />O Sponsored <br />O Small Contributor Committee <br />0 Political Partv/Central Committee <br />3. Committee Information <br />❑ Primarily Formed Ballot Measure <br />Committee <br />O Controlled <br />O Sponsored <br />(Also Complete Part 6) <br />❑ Primarily Formed Candidate/ <br />COMMITTEE NAME (OR CANDIDATE'S NAME IF NO COMMITTEE) <br />Jan Marx for Mayor 2016 <br />Officeholder Committee <br />(Also Complete Part 7) <br />LD NUMBER <br />STREETADDRESS (NO P.O. BOX) <br /> <br />CITY STATE ZIP CODE AREA CODE/PHONE <br />San Luis Obispo CA 93405 ( <br />MAILING ADDRESS (IF DIFFERENT) NO. AND STREET OR P.O. BOX <br />Same <br />Ci —1y S TA'I E ZIP CODE AREA CODE!—PHONE <br />OPTIONAL: FAX/ E-MAIL ADDRESS <br /> <br />4. Verification <br />I have used all reasonable diligence in preparing and reviewing this statement and to the best of my <br />certify under penalty oferju er th Ics of the State of California that the foregoing is true and <br />Executed on ��� it __(o By <br />tiaIe <br />Executed ons �' By <br />Executed on LIald By <br />Date of election if appli <br />(Month, Day, Year) <br />Date Stamp <br />RECEIVED <br />OCT 24 2W <br />LO CITY CLERK <br />® Preelection Statement <br />❑ Semi-annual Statement <br />❑ Termination Statement <br />(Also file a Form 410 Termination) <br />❑ Amendment (Explain below) <br />Treasurer(s) Gregory Ty Griffin <br />I Page I of t -'k <br />❑ Quarterly Statement <br />❑ Special Odd -Year Report <br />NAME OF TREASURER <br /> <br />MAILING ADDRESS <br />CITY San Luis Obispo STATE CA ZIP CODE 93401 AREACODE/PHONE <br />NAME OF ASSISTANT TREASURER, IF ANY Jan Marx <br /> <br />MAILING ADDRESS <br />San Luis Obispo CA 93405 <br />CITY STATE ZIP CODE AREACODE/PHONE <br /> <br />QPnONLA-1 FAX r F -MALI ArHnRFSR <br /> <br /> <br />Executed on By <br />usm Signature or>,.onvoliing Officeholder, Candidate, State measure rroponen[ <br />FPPC Form 460 (Jan/2016) <br />FPPC Advice: (866/275-3772) <br />