HomeMy Public PortalAboutForm 410 Terminationatement of Organization
-cipient Committee
Iltement Type ❑ Initial
Not yet qualified ❑ or
Date qualified as committee
Committee Information
Type or print in ink
❑ Amendment
List I.D. number:
Date qualified as committee
(If applicable)
NAME OF COMMITTEE i
Termination — See Part 5
List I.D. number:
1 _J__L_L1
Date of Termination
Date Stamp
FEB 0 2 2012
UTY CLERK
CITY OF CLARENC
2. Treasurer and Other Principal Officers
NAM�nF TREASURIt
/ _
. , PG9e[YC_ C
STREETADDRESS-(NO P.O. BOX)
S�
STREETADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE
64v /U��-�f� ,4v�
CITY / STATE ZIP CODE AREACODE/PHONE NAME OF ASSISTANT TREASURER, IF ANY
STREETADDRESS (NO P.O. BOX)
MAILING ADDRESS (IF DIFFERENT)
STATEMENT OF ORGANIZATION
OPTIONAL: FAX/ E-MAIL ADDRESS
COUNTY OF DOMICILEI COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
CITY STATE ZIP CODE AREACODE/PHONE
NAME OF PRINCIPAL OFFICER(S)
STREETADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
Attach additional information on appropriately labeled continuation sheets. n
L J
Verification
I have used all reasonable diligence in preparing this statement and to the best of my no%vIedge 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 correc . / r /�/•
Executed on
DATE
Executed on L (f' -
DATE
Executed on
DATE
Executed on
DATE
By
By
By
DRIER OR ASSISTANT TREAS
RE OF CONTROLLING OFFICEHOLDER. CANDIDATE. OR
OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (April/2011)
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