HomeMy Public PortalAboutForm 410 Initial~tatempnt of Organization
Recipient Coinfnittee
Statement Type ~Inltlal
Not yet quallfled~ or
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~ Amendment ~ Termination -See Part 5
Ust I.D. number. List I.D. number.
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Date qualified as committee
Date qualified aS COrtHi$tlee ' -' 0 d l~rmineh'ori
(h ~pplkeble)
Date Stamp
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CA SCCR(7c~lY u~~TA
STATEMENT OF ORGANIZATION
For Orticlal Use Only
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1. Committee Information 2. Treasurer and Other Principal Officers '
NAME OF COMMITTEE NAME OF TREASURER
. O A ~ l T) o N i0 I'',Z-~SO~v~ G~~~.Em o~v i 'S
Gf-h9~.~ C~~-
STREET ADDRESS (NO P.O. BOX)
1'0 3 ~ ~A~ V l ~--LE ~A~2 ,
CITY STATE ZIP CODE AREA CODE/PHONE
I~ ~£~'-'I oNl ~ `'1 ~7~~ goy-(off -53~9s
MAILING ADDRESS (IF DIFFERENT)
OPTIONAL: FAX / E-MAIL ADDRESS
C~-o L ~o L.~ ao r rJ f-~ / L
MAIUNG ADDRESS
(03~ G~1-~'yI LLF X12 .
CITY STATE ~ ZIP CODE AREA CODElPHONE
C r'~-12~ o ~~ T~ C A ~~ ~ l l ~ C9 -~ 2~S-S35S
NAME OF ASSISTANT TREASURER, I~AN'i
MAILING ADDRESS ~ J /~
CITY STATE ZIP CODE AREA CODE/PHONE
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE
COUNTY OF DOMICILE I COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
(_.,(' S ASV G E?~S
ch additionallnlormatlon on appropriately labeled continuation sheets.
MAILING ADDRESS r/
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 end complete. I certify under penalty of
perjury under the laws of the State of California that the foregoing is true and correct.
2S 7-x=0 ~ /'~ ~~~~
Executed on 1 ~,~.-(;c,, , 6y C ~:/L~_ ~-<.~c?f~~~-
ATE SIGNATURE OF TREASURER Ofl ASSISTANT TREASURER
Executed On
DATE
Executed on
_ DATE
EXeCUted On
DATE
SIGNATURE OF CONTROLLING OFFICEHOLDER, 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 41p (8/99)
For Technical Asslstenee: 916/322-5660
Statement of Organization
Recipienf Committee
INSTRUCTIONS ON REVERSE
STATEMENT OF
Co ~1-c,r -r-) o N 7~ ~2~SE~2.~.i~ Gc-~4 ~~m ortT 's ~:a9 c~72
.D. NUMBER
4. Type Of Committee complete the applicable sections.
• List the name o1 each controlling officeholder, candidate, or state measure proponent. If candidate or officeholder controlled, also list the elective office sought or held, and
district number, N 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.
• List the financial institution and the disposition of surplus funds (controlled 'candidate election' committees only)
NAME OF FINANCIAL INSTITUTION
AREA CODE/PHONE
BANK ACCOUNT NUMBER
DATE OPENED
ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE DISPOSITION OF SURPLUS FUNDS
Primarily forrned to support or oppose specific candidates or measures In a single electon. List below:
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO.OR LETTER)
'~ l~ t7. ?1jC'(;~ - G~ r~ N c% k-t) ~ N r) ,~ C" t c, % ~ 7 C i ~T
~1 ~P~~t,~in~(; a- ~T~fvi~ zanK: ~cE,c_li nv~l car ;-~ T
--ti~~G~~ i ~'~
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
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1~~'J Eh1T r~} C.~ 1`{'17 ~~ ~ V o(. 'v~-~:~ h-~
1Od~ VN~ vC~_.S~
CHECK ONE
oPVOSe
FPPC Form 410 (8/99)
For Teehnlcet Aselstenee: 916/322-5660
I
ELECTIVE OFFICE SOUGHT OR HELD ~
NAME OF CANOIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
Sty±emer~t of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
4. Type of Committee (contlnued)
• • Not fom~ed to support or oppose specific candidates or measures In a single electlon. Check only one box:
CITY Committee ~ COUNTY Committee ~ STATE Committee
P~p~ ~
OF
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
• • • • Ust addldonai sponsors on an attachment r
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
MAILINCa ADDRESS NO. AND STREET CITY STATE ZIP CODE
= • • • = ' • ~ (For purposes of spedal election contributlon limits)
5. Termination Requirements By signing the velificatlon, 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 ailed 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 Manual on Cam2aign Disclosure Provisions of the Political Reform Act 1 r Elected Officerc. Candidates and their Controlled Committees
(Manual A).
-- Additional filing obligations will be incurred ii, 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 (8/99)
For Technical Asslatence: 916822-5660
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