HomeMy Public PortalAboutForm 410 Ty Peabody 2022Statement of Organization
Recipient Committee
Statement Type ❑ Initial
Q Not yet qualified
or
Q Date qualification threshold met
1. Committee Information
0 Amendment
Date qualification threshold met
/ /
I.D.Number st# ctCa
(if applicable)
NAME OF COMMITTEE 1-.'
® Termination — See Part 5
Date of termination
7-1
JA`,
Oate Stamp
CALIFORNIA 410
FORM
for Official use only
2. Treasurer and Other Principal Officers
NAME OF TREASURER
STREET ADDRESS (NO P.O. BOX)
'76471
ST
REET
R 1OP y 1) „1..k.
CITY
CITY
STATE ZIP CODE AREA CODE/PHONE
STATE ZIP CODE AREA CODE/PHONE
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FULL MAILING ADDRESS (IF DIFFERENT)
•V
NAME OF ASSISTANT TREASURER, IF ANM
STREET ADDRESS (NO PO. BOX)
E-MAIL ADDRESS (REQUIRED) / FAX (OPTIONAL)
COUNTY OF DOMICILE
IUR IC'TTIIOWHERE COMMITTEE IS ACTI V
CITY
STATE
ZIP CODE AREA CODE/PHONE
NAME OF PRINCIPAL OFF ICER(SI
Attach additional information on appropriately labeled continuation sheets.
STREET ADDRESS (NO P.O. BOX)
CITY
STATE ZIP CODE
AREA CODE/PHONE
3. Verification
I have used all reasonable diligence in preparing this stamen_ and to the best of my knowledge the information contained herein is true and complete. I certify under
penalty of perjury under the laws of the
OR ASSISTANT TREASURER
SIGNATURE OF�ONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
i
FPPC Form 410 (August/2018)
FPPC Advice: advicePfopc.ca.gov (866/275-3772)
www.fppc.ca.eov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
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• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION
ADDRESS ; :„.,„ia .yam t
.4. Type of Committee Complete the applicable sections.
Controlled Committee
AREA CODE/PHONE
r? 3 Sts
CALIFORNIA A 1 0
FORM "�F
Page 2
L0. NUMBER
Lt. tiL
BANK ACCOUNT NUMBER
‘, 2. kt. clItt 1 Rl
CITY STATE ZIP CODE
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,
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT
ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE)
YEAR OF
ELECTION
PARTY
CHECK ONE
.1. 1.%
1
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.eov (866/275-3772)
www.fppc.ca.eov