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Home My Public Portal About01. Form 410C (Grp m 0-,n+ Statement of Organization Recipient Committee Statement Type //// /( N6 `>; 0`1,, REC Date Stamp VED AND FILED 0 of the Secretary of State State of California q °V � 2 2023 CALIFORNIA 410 FORM .-, Fos Official Use Only 1 23NOV _ � # 50 . !j Initial 0 Not yet qualifiedOE 0 Date qualification threshold met / / ■ Amendment IITermination — SEN N' o t Et �y Date of termination "' /-/ Date qualification threshold met / / 1. Committee Information I.D. Number i a • . Iicable NAME OF COMMITTEE Corey Calaycay for Claremont City Council 2024 2. Treasurer and Other Principal Officers NAME OF TREASURER Susan Pearson STREET ADDRESS (NO P.O. BOX) 2461 San Jacinto Ct STREET ADDRESS (NO P.O. BOX) 1555 W Base Line Road CITY STATE ZIP CODE AREA CODE/PHONE Claremont CA 91711 909 921-4357 CITY STATE ZIP CODE AREA CODE/PHONE Claremont CA 91711 909 593-5913 NAME OF ASSISTANT TREASURER, IF ANY FULL MAILING ADDRESS (IF DIFFERENT) STREET ADDRESS (NO P.0.BOX) E-MAIL ADDRESS (REQUIRED) / FAX (OPTIONAL) corey@coreycalaycay.com CITY STATE ZIP CODE AREA CODE/PHONE COUNTY OF DOMICILE Los Angeles JURISDICTION WHERE COMMITTEE IS ACTIVE Claremont, CA NAME OF PRINCIPAL OFFICERS) Attach additional information on appropriately labeled continuation sheets. STREET ADDRESS (NO PO BOX) CITY STATE ZIP CODE AREA CODE/PHONE 3. Verification 1 have used all reasonable diligence in preparing thi penalty of perjury under the laws of the State of Executed on Ctqc3 U"' /y By DATE Executed on Ock 2.2..) 2 y DATE Executed on By DATE Executed on By DATE tate or .- t t and to the best of my knowledge the information contained herein is true and complete. I certify under t the foregoing is true and correct. ) SIGNATURE OF TREASURER OR ASSISTANT TREASURER RE OF CONTROLLING 0 DER, CA .ATE, OR TATE MEASURE PROPONENT SIGNATURE OF CONTROLLING OFFICEHOLD CANDIDATE, OR S EASURE PROPONENT SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT FPPC Form 410 (August/2018) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE CALIFORNIA 410 FORM Page 2 COMMITTEE NAME Corey Calaycay for Claremont City Council 2024 I.D. NUMBER • All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION None AREA CODE/PHONE BANK ACCOUNT NUMBER ADDRESS 4. Type of Committee Complete the applicable sections. Controlled Committee CITY 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. NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY CHECK ONE C:nrPv C:alavrav City Council MPmhPr 2(19.4 Nonpartisan Partisan (list political party below) Nonpartisan Partisan (list political party below) Primarily Formed Committee 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, CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE SUPPORT OPPOSE SUPPORT OPPOSE FPPC Form 410 (August/2018) FPPC Advice: advice a1 fppc.ca.sov (866/275-3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME Corey Calaycay for Claremont City Council 2024 I.D. NUMBER 4. Type of Committee (Continued) General Purpose Committee Not formed to support or oppose specific candidates or measures in a single election. Check only one box: 0 CITY Committee 0 COUNTY Committee 0 STATE Committee PROVIDE BRIEF DESCRIPTION OF ACTIVITY Sponsored Committee List additional sponsors on an attachment. NAME OF SPONSOR NDUSTRY GROUP OR AFFILIATION OF SPONSOR STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE AREA CODE/PHONE Small Contributor Committee Date qualified 5. Termination Requirements By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or ponent certify that all of the following conditions 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. FPPC Form 410 (August/2018) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fpoc.ca.gov err Statement of Organization Recipient Committee Statement Type REcavE OCT 3 0 2023 CITY CLERK CITY OF CLAREMONT ,ALIFORNIA FORM 410 For Official Use Only !'A Initial 0 Not yet qualified Or 0 Date qualification threshold met / / • Amendment ■ Termination — See Part 5 Date of termination / Date qualification threshold met /----/ 1. Committee Information I.D. Number i c..ficable 2. Treasurer and Other Principal Officers NAME OF COMMITTEE Corey Calaycay for Claremont City Council 2024 NAME OF TREASURER Susan Pearson STREET ADDRESS (NO P.O. BOX) 2461 San Jacinto Ct STREET ADDRESS (NO P.O. BOX) 1555 W Base Line Road CITY STATE ZIP CODE AREA CODE/PHONE Claremont CA 91711 909 921-4357 CITY STATE ZIP CODE AREA CODE/PHONE Claremont CA 91711 909 593-5913 NAME OF ASSISTANT TREASURER, IF ANY FULL MAILING ADDRESS (IF DIFFERENT) STREET ADDRESS (NO P.O. BOX) E-MAIL ADDRESS (REQUIRED) / FAX (OPTIONAL) corey@coreycalaycay.com CITY STATE ZIP CODE AREA CODE/PHONE COUNTY OF DOMICILE Los Angeles JURISDICTION WHERE COMMITTEE IS ACTIVE Claremont, CA NAME OF PRINCIPAL OFFICER(S) Attach additional information on appropriately labeled continuation sheets. STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE 3. Verification I have used all reasonable diligence in preparing this penalty of pe ' ry under the laws of the State of C. ; ri'. t at the foregoing is true and correct. Executed on 4--/, at gy DATE r Executed on O . �2_ DATE Executed on By DATE Executed on By DATE ate nt and to the best of my knowledge the information contained herein is true and complete. I certify under �L J SIGNATURE OF TREASURER OR ASSISTANT TREASURER SIGNATURE . CO ` ROLLING OFFICEHOLDE ANDI . •.TE, OR STA . EA RE PROPONENT SIGNATURE OF CONTR.. OFFICEHOLDER, CANDIDATE, OR STATE MEASU' - ;' OPONENT SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT FPPC Form 410 (August/2018) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME Corey Calaycay for Claremont City Council 2024 Page 2 I.D. NUMBER • All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION None AREA CODE/PHONE BANK ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE . ype o ommi - ee Comp ete the applicable sections. Controlled Committee • 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. NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY CHECK ONE CnrQv Calavrav City Cnnnril Memhpr ?024 Nonpartisan Partisan (list political party below) Nonpartisan Partisan (list political party below) Primarily Formed Committee 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. CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE SUPPORT OPPOSE SUPPORT OPPOSE FPPC Form 410 (August/2018) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE CALIFORNIA 410 FORM Page 3 COMMITTEE NAME Corey Cataycay for Claremont City Council 2024 I.D. NUMBER 4. Type of Committee (Continued) General Purpose Committee Not formed to support or oppose specific candidates or measures in a single election. Check only one box: 0 CITY Committee 0 COUNTY Committee 0 STATE Committee PROVIDE BRIEF DESCRIPTION OF ACTIVITY Sponsored Committee List additional sponsors on an attachment. NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE AREA CODE/PHONE Small Contributor Committee 0 / Date qualified . ermina on • equirements By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or ponent certify that all of the following conditions 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. FPPC Form 410 (August/2018) FPPC Advice: adviceCa'fppc.ca.gov (866/275-3772) www.fppc.ca.gov