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HomeMy Public PortalAboutForm 410 InitialStatement of Organization Recipient Committee S4 atement Type l� Type or print in ink E Initial [] Afnendment Not yet qualified ©/or List I.D. number: I --IJ Date qualified as committee Date qualified as committee (If applicable) 1. Committee Information NAME OF COMMITTEE PO ❑ Ter minatlon See Part 5 List I.D' number, I�D'ate,ofTei•mination l STATE ANIZATLO Date Stamp _ 9iQg in t e office Oi r F, �rf the ,., office o t of Stat Of _} of the State of California JAN 10 2011 R'� ti n EBRA BOWEN Secretary OR � '3 ecretanr of State 2. Treasurer and Other Principal Officers STREETADDRESS (NO P.O. BOX) STREETADDRESS (NO P.O. BOX) i CITY STATE ZIP CODE AREA CODE/PHONE /-� 1?) CITYSTATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY 3 X �s MAILING ADDRESS (IF DIFFERENT) STREETADDRESS (NO P.O. BOX) OPTIONAL: FAX/ E-MAILLADDRESS c CUUNTY OF DOMICILEI COUNTY WHERE COMMITTEE ISACTIVE IF DIFFERENT THAN COUNTY OF DOMI"ILE Ley �.� t9ls Attach additional information on appropriately labeled continuation sheets. CITY STATE ZIP CODE AREA CODE/PHONE NAME OF PRINCIPAL OFFICER(S) STREETADDRESS (NO P.O. BOX) STATE ZIP CODE AREA CODE/PHONE O 3. Verification I have used all reasonable diligence in preparing this statement and to the best of my know dge t e information ontzfRed 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 ✓ ` '� Z(,�� By_ DATE SIGNATURE OF TREASUP,ER OR ACSlcronir row o. ��., Executed on DATE By i SIGNATURE OF CONTROLLING OFF ICEHOLUER 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 (June/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772) Statement of Organization a Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME 4. Type of Committee Complete the applicable sections. STATEMENT OF ORGANIZATI • 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. O • 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. ELECTIVE OFFICE SOUGHT OR HELD KI A nnc nc r`AKIM[ nATC/nGClr`P"r)I nFR/STATF MFASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY (��!}, (% C Vrs� c c 1.� o n -Partisan ❑ Non -Partisan • List the financial institution where the campaign bank account is located (controlled "candidate election" committees only) NAME OF FINANCIAL INSTITUTION ADDRESS ! _ AREA CO qtqDEMf�!!JJ I� CITY BANK STATE NUMBEK ZIP CODE gIR.II ffa7r,rM 21T =I,- Primarily formed to support or oppose specific candidates or measures in a single election. List below: CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) (INCLUDE DISTRICT NO- CITY OR COUNTY, AS APPLICABLE) CHECK ONE FPPC Form 410 (June/09) FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)