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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. Doug Ose for Congress
9321 Silverbend Lane ADDRESS (number and street)
Check if different than previously Elk Grove CA 95624
reported. (ACC)