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Statement of Organization
Recipient Committee
Statement Type ® Initial
® Not yet qualified
or
O Date qualified as committee
❑ Amendment ❑ Termination — see Part 5
Date qualified as committee Date of termination
JAN 2 12020
CITY CLERK
CIl Y OF CLAREMONT
For Official Use Only
1..Committee lnformafiI.D. Number
on Z. Treasurer and Oilier Principal Officers ,
(if applicable)
NAME OF COMMITTEE NAME OF TREASURER
Jennifer Stark for Claremont City Council 2022 Simon Brown
STREET ADDRESS (NO P.O. BOX)
STREET ADDRESS (NO P.O. BOX)
242 Eagle Grove Avenue
CITY STATE ZIPCODE AREACODE/PHONE
Claremont CA 91711 909-913-2580
MAILING ADDRESS (IF DIFFERENT)
E-MAIL ADDRESS (REQUIRED) / FAX (OPTIONAL)
jenniferstarkis@gmail.com
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE
Los Angeles County Claremont (Los Angeles County)
1420 N Claremont Blvd, Ste 204C
CITY STATE ZIP CODE AREA CODE/PHONE
Claremont CA 91711 909-541-0713
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREACODE/PHONE
NAME OF PRINCIPAL OFFICERS)
Laura Roach
STREET ADDRESS (NO P.O. BOX)
310 W Radcliffe Dr
CRY STATE ZIP CODE AREACODE/PHONE
Attach additional information on appropriately labeled continuation sheets. Claremont
CA 91711 626-720-7798
3. ,Veri cation .
I have used all reasonable diligence in preparing this statemenLand to the b of my knowledge the information contained herein is true and complete. I certify under
penalty of perjury under he laws of the State of Californi t the foregoin rue and correct.
Executedon Z0 By '
D -7 �IE
OFTREA R ASSISTANTT SURER
Executed on G �By ", f' / G ! ` --
OA (/ SIGNATURE OR CONTROLLING 07ICE DER, CANDIDATE, OR STATE M -MMM PROPONENT
Executed on By
DATE
STATE
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (October/2017)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
14
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME I.D. NUMBER
Jennifer Stark for Claremont City Council 2022
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION
ADDRESS
4. Type: of Committee Complete the applicable sections,
Cm
BANK ACCOUNT NUMBER
STATE ZIP CODE
• 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
Jennifer Stark
Claremont City Council
2022
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)
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME.
CANDIDATES) OFFICE SOUGHT OR HELD OR MEASURES) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE
SUPPORT I OPPOSE
OPPOSE
FPPC Form 410 (October/2017)
Clear Pae Print FPPC Advice: advice@fppc.ca.gov (866/275-3772)
g www.fppc.ca.gov
A
Statement of Organization ��
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 3
Jennifer Stark for Claremont City Council 2022
4. Type of Committee. (Continued)
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee ❑ Political Party/Central Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
List additional sponsors on an attachment.
NAME OF SPONSOR
STREET ADDRESS NO. AND STREET
.� Small Contributor Committee �
CITY
GROUP OR AFFILIATION OF SPONSOR
STATE ZIPCODE AREACODEfPHONE
S. Termination, Requirements By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder,, or proponent certify that all of the following cond,'Ition; 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 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.
Clear Page Print
FPPC Form 410 (October/2017)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov