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1. Committee
Information 1.0. Number
I a. •Acablr
2 Treasurer and
Other Principal Officers
NAME OF COMMITTEE
Elect Ted Mertens I.W. City Council 2022
NAME OF TREASURER
J.L. Mertens
STREET ADDRESS (NO P.O. BOX)
74972 Saguaro Lane
STREET ADDRESS (NO P0. BOX)
74972 Saguaro Lane
CITY STATE ZIP CODE AREA CODE/PHONE
Indian Wells CA 92210 7607768186
CITY STATE ZIP CODE
Indian Wells CA 92210
AREA CODE/PHONE
7607768186
NAME OF ASSISTANT TREASURER, IF ANY
FULL MAILING ADDRESS (IF DIFFERENT)
STREET ADDRESS (NO P.O. BOX)
E-MAIL ADDRESS (REQUIRED) / FAX (OPTIONAL)
TedMertens20222 @gmail. com
CITY STATE ZIP CODE AREA CODE/PHONE
COUNTY OF DOMICILE
Riverside
JURISDICTION WHERE COMMITTEE 15
Indian Wells
ACTIVE
NAME OF PRINCIPAL OFFICER(5)
Ted J. Mertens
STREET ADDRESS (NO P.O. BOX)
74972 Saguaro Lane
Attach additional information on appropriately labeled
continuation sheets.
CITY STATE ZIP CODE AREA CODE/PHONE
Indian Wells CA 92210 7607768186
3. Verification
h b f
I d e *), m o In nr atiA n n rntainPri nrein is true an• complete. I certify under
I have used all reasonable
m prepar)ng trlls statement and to t e est o my now e g
penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Executed on 8/25/2022
DATE
8/25/2022
Executed on By
DATE
By
Executed on Bte'
DATE
Executed on By
DATE
SIGNATURE OF TREASURER OR ASSISTANT TREASURER
SIGNATURE OF CONTROLLING dFFICEH OLDER, CANDIDATE, OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (August/2018)
FPPC Advice: advicePfpoc.ca.eov (866/275-3772)
wWw.fppc.ca.goV
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Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
CALIFORNIA 4'1 V ry
FORM
Page 2
I.O. NUMBER
COMMITTEE NAME
Elect Ted Mertens I.W. City Council 2022
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION
Wells Fargo Bank
AREA CODE/PHONE BANK ACCOUNT NUMBER
7605683460
ADDRESS
74105 El Paseo
4. Type of Committee Complete the' applicable sections.
Controlled Committee
CITY
Palm Desert
STATE ZIP CODE
CA 92260
• List the name of each controlling officeholder, candidate, or state measure proponent. If candidate or officeholder controlled,
also list the elective office sought or held, and district number, if any, and the year of the election.
• List the political party with which each officeholder or candidate is affiliated or check "nonpartisan." Stating "No party preference" is acceptable
• If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee.
EHOLDER/STATE MEASURE PROPONENT
ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE)
YEAR OF
ELECTION
PARTY
CHECK ONE
Ted J. Mertens
Indian Wells City Council
2022
Nonpartisan
Partisan
(list political party below)
Nonpartisan
Partisan
(list political party below)
Primarily Formed Committee
Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(5) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER)
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME.
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
SUPPORT
OPPOSE
SUPPORT
OPPOSE
FPPC Form 410 (August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fpnc.ca.$ov