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REPORT OF RECEIPTS FEC AND DISBURSEMENTS FORM 3 For An Authorized Committee Office Use Only
1. NAME OF TYPE OR PRINT Example: If typing, type 12FE4M5 COMMITTEE (in full) over the lines. Mark Takai for Congress
P.O. Box 2267 ADDRESS (number and street)
Check if different than previously Pearl City HI 96782
reported. (ACC)