HomeMy Public PortalAboutForm 410 TerminationStatement of Organization Type or print in ink
Recipient Committee
s Statement Type ❑ Initial ❑ Amendment
Not yet qualified ❑ or List I,D.number:
qualified as committee Date qualified as committee
(If applicable)
1. Committee Information
NAME OF COMMITTEE
Committee to Elect Sam Pedroza, Claremont City Council 2011
STREET ADDRESS (NO P.O. BOX)
580 Cinderella Dr
CITY
® Termination — See Part 5
List I.D. number:
#1292533
11 r 15 t 11
Date of Temiination
STATE ZIP CODE AREACODEIPHONE
STATEMENT OF ORGANIZATIDN
2. Treasurer and Other Principal Officers
NAME OF TREASURER
Brian Teuber
STREET ADDRESS (NO P.O. BOX)
553 Redlands Ave
CITY STATE ZIP CODE AREACODE(PHONE
Claremont CA 91711 (909) 802-4598
NAME OF ASSISTANT TREASURER, IF ANY
Claremont CA 91711 (909) 621-0615
STREET ADDRESS (NO P.O. BOX)
MAILING ADDRESS (IF DIFFERENT)
CITY STATE ZIP CODE AREACODE/PHONE
OPTIONAL: FAX i E-MAIL ADDRESS
NAME OF PRINCIPAL OFFICER(S)
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE STREET ADDRESS (NO P.O. BOX)
Los Angeles
CITY STATE ZIP CODE AREACODEIPHONE
Attach additional information on appropriately labeled continuation sheets.
O
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 1130112 By '
ATE SIGNATUREOFTRE SIJRERORASSISTANT TREASURER
Executed on 1130/12 By
DATE SIGNATURE 0 CONTROLLING OFFICEEHO f
ER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (April/2011)
FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772)
Statement of Organization OF ORGANIZATION
Recipient Committee AGALIF�RN' '- ,i
4r 4� r�M
116 INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME I.D. NUMBER
Committee to Elect Sam Pedroza, Claremont City Council 2011 1292533
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, if any, and the year of the election.
• List the political party with which each officeholder or candidate is affiliated or check "non-partisan." O
• If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee.
ELECTIVE OFFICE SOUGHT OR HELD
NAME OF CANDIDATEfOFF10EHOLD ERISTATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
Sam Pedroza
City Councilmember
2011
® Non -Partisan
❑ Non -Partisan
• List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION AREA CODE/PH ONE BANK ACCOUNT NUMBER
Bank of America (909) 865-2424 02056-47031
ADDRESS CITY STATE ZIP CODE
339 Yale Ave Claremont CA 91711 O
Primarily formed to support or oppose specific candidates or measures in a single election. List below,
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT N0, OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE
FPPC Form 410 (April/2011)
FPPC Toll -Free Helpline: 866/ASK-FPPC (8661275-3772)