HomeMy Public PortalAboutForm 410 AmendmentStatement of Organization -4-
Date Stamp
Recipient Committee
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iVED AND FILED
Secretary of State
for Official Use Only
Statement Type
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initial
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Date of termination
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NAME OF COMMITTEE _
NAME OF TREASURER
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STREET TDDRSS (NO.O. BOX)
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STREET ADDRESS (NO P.O. BOX)
CITY
STATE ZIP CODE
AREA CODE/PHONE
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CITY STATE ZIP CODE AREA CODE/PHONE
NAME OF ASSISTANT TREASURER, IF ANY
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FULL MAILING ADDRESS (IF DIFFERE T)[
STREET ADDRESS (NO P.O. BOX)
E-MAIL ADDRESS (REQUIRED) / FAX (OPTIONAL)
CITY
STATE ZIP CODE
AREA CODE/PHONE
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COUNTY OF DOMICILE
JURISDICTION WHERE COMMITTEE IS ACTIVE
NAME OF PRINCIPAL OFFICER(S)
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STREET ADDRESS (NO P.O. BOX)
Attach additional information on appropriately labeled continuation sheets.
CITY STATE ZIP CODE
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AREA CODE/PHONE
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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 CaliijgAnia that the foregoing is true and correct.
Executed on C", tr / ` ���By
DATE
Executed. on oc� /l Ak Z z%zo By
DATE
Executed on By
DATE
Executed on By
DATE
SIGNATURE OF TREASURER OR ASSISTANT TREASURER
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 410(August/2018)
FPPC Advice: advice@fppc.ca.Qov (866/275-3772)
www.fppc.ca.gov
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Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION I AREA CODE/PHONE
ADDRESS
CITY
BANK ACCOUNT NUMBER
STATE ZIP CODE
Page 2
I.D. NUMBER
14 Z -1
• 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 "nonpartisan" Stating "No party preference" is acceptable
• 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 YEAR OF PARTY
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) ELECTION CHECK ONE
Nonpartisan Partisan (list political party below)
Nonpartisan Partisan (list political party below)
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 NO. OR LETTER) CANDIDATES) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
. IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME. (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE
SUPPORT OPPOSE
SUPPORT OPPOSE
FPPC Form 410(August/2018)
FPPC Advice: advicePfppc.ca.g_ov (866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE
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Page 3
I.D. NUMBER
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Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
• List additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
J
STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE AREA CODE/PHONE
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Date qualified
• 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
Government Code Section 89519.
— Leftover funds of ballot measure committees may be used for political, legislative or,governmental purposes under Government Code Sections 89511 -
89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5.
FPPC Form 410 (August/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov-