HomeMy Public PortalAboutForm 410Stdlem2nt Of OrganlZatlOn STATEMENT OF ORGANIZATION
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Rec.?ient Committee ( ~ ~ ~ ~ ~° ,~ ,.
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RECEIVLL) Ai"J t~lt-E'~ • '
Statement T e Inltlal ~ P ITICI~L RE~O~iM pIVIS-~~~~~
YP ^ ^ Amendment ®Terminatlon -See Part 50FFI E OF SECREI Al?Y G.= '%i i'~ % ~= For Ofliclal Use Onty
Not yet qualified ^ or List I _D_ number: _ List I. D. number:
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Date qualified as committee ;- . Date qualified as committee Date o1 Termination (~~ SECRETAF?Y U ~ ~ ~~T
1. Committee Information ~ ~ ~ ~ ' 2. Treasurer and Other Principal Officers
NAME OF COMMITTEE NAME OF TREASURER
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STREET ADDRESS (NO P.O. BOX)
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CITY STATE ZIP CODE AREACODE/PHONE
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MAILING ADDRESS (IF DIFFERENT)
OPTIONAL: FAX / EMAIL ADDRESS
9og-6a~(.t437
COUNTY OF DOMICILE I COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
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Attach additional Information on appropriately labeled continuation sheets.
MAILING ADDRESS ,
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CITY STATE ZIP CODE AREA CODE/PHONE
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NAME OF ASSISTANT TREASURER, IF ANY
MAILING ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S). IF APPLICABLE
MAILING ADDRESS
CITY
STATE ZIP CODE AREA CODE/PHONE
3. Verification
I have used all reasonable diligence in preparing this statement 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 State of California that the foregoing is true and correct.
Executed on Q I ~ By
DATE
Executed on ~ y-~-( 2.3 Z.~b l
ATE
6(eCUted Orl
DATE
Executed On
DATE
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE. OR STATE MEASURE PROPONENT
FPPC Form 41p (8/99)
For Technical Assistance: 916/322-5660
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
fEE NAME
~A ~ ` iF~~n ~z ~ot~N~~L
STATEMENT OF ORGANIZATION
Page 2
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4. Type Of Committee Complete the applicable sections.
. -.
• 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, i( any, and the year of the election.
• List the political party with which each officeholder or candidate is affiliated or check "non-partisan."
• 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 APPLICABLEI YEAR OF ELECTION PARTY
[~TJon-Partisan
Non-Partisan
• List the financial institution and the disposition of surplus funds (controlled "candidate election° committees only)
NnME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER DATE OPENED
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ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE DISPOSITION OF SURPLUS FUNDS
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• - • Primarily formed to support or oppose speci0c candidates or measures In a single election. List below:
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO: OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE
SUPPORT OPPOSE
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OPPOSE
FPPC Form 410 (fi/99)
For Technical Assistance: 916/322-5660
statement of Organization
P.Acipient Committee
INSTRUCTIONS ON REVERSE
4. Type of Committee (Continued)
' ' ~ Not formed to support or oppose specllic candidates or measures In a single election. Check only one box:
[~ CITY Committee [] COUNTY Committee ~ STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
STATEMENT OF ORGAN
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' ' ' ' Llst additional sponsors on an attachment.
NAMEOFSPONSOR
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
CITY
STATE ZIP CODE
• ' ' ' ~ ' ~ (For purposes of special election contributlon limits)
5. Termination Requirements By signing the veriflcatlon, the treasurer, assistant treasurer and/or candidate, officeholder, or proponent certify that ell of the following conditlons have been met:
• This committee has ceased to receive contributions and make expenditures;
• This committee does not anticipate receiving contributions or making expenditures in the future;
• This committee has eliminated or has no intention or ability to discharge all debts, loans received, and other obligations;
• This committee has no surplus funds; and
• This committee has filed all campaign statements required by the Political Reform Act disclosing all reportable transactions.
-- There are restrictions on the disposition of surplus campaign funds held by elected officers who are leaving office and by defeated candidates. Refer to
the Information anus! on Campaign Disclosure Provisions of the Politi al Qotorm Act f r Elected Officers Candidates and their Controlled CommltteE
(Manual A)
-- Additional filing obligations will be incurred if, after terminating, the committee receives or spends any funds, or receives the forgiveness of a loan
repayments of loans made to others, or any other receipts.
FPPC Form 410 (lt/99)
For Technleal Assistance: 916!322-5660
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