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Home My Public Portal About02. Form 410 Amendment (Qualified 12-11-23)Statement of Organization Recipient Committee Statement Type ❑ initial o Not yet qualified Or 0 Date qualification threshold met /-•/ ® Amendment Date qualification threshold met 12 11 2023 0 Termination — See Part 5 Date of termination DEC 12 2023 CITY CLERK For Official Use Only 1. Committee Information I.D. Number 1464043 (If opplicoble) 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 CITY Claremont STATE ZIP CODE CA 91711 STREET ADDRESS (NO P.O. BOX) 1555 W Base Line Road EMAIL ADDRESS OF TREASURER (REQUIRED) spearson67@gmail.com AREA CODE/PHONE 909 921-4357 CITY Claremont STATE ZIP CODE AREA CODE/PHONE CA 91711 909 593-5913 NAME OF ASSISTANT TREASURER, IF ANY Bill Buehler FULL MAILING ADDRESS (IF DIFFERENT) STREET ADDRESS (NO P.O. BOX) 304 E Miramar Ave CITY Claremont STATE ZIP CODE CA 91711 E-MAIL ADDRESS OF COMMITTEE (REQUIRED) / FAX (OPTIONAL) corey@coreycalaycay.com EMAIL ADDRESS OF ASSISTANT TREASURER (REQUIRED) bill@mttorch.com AREA CODE/PHONE 909 262-9922 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 EMAIL ADDRESS OF PRINCIPAL OFFICER(S) (REQUIRED) AREA CODE/PHONE 3. Verification 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 California that the foregoing is true and correct. Executed on /g -/01-X3 By DATE 'I Executed on / Z /2__- L.f�3 By DATE Executed on By DATE Executed on By DATE GNATURE OF TREASURER OR ASSISTANT TREASURER 5IGNATtLRE OF CONTROLLING OFFICEH N� •AT E, ORS TE MEASURE PROPONENT SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR ' MEASURE PROPONENT SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT FPPC Form 410 (October/2023) FPPC Advice: advketaifppc.ca.gov (866/275-3772) www.fppc.ca.Rov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE CALIFORNIA A 1 O FORM '•F Page 2 COMMITTEE NAME Corey Calaycay for Claremont City Council 2024 I.D. NUMBER 1464043 • All committees must list the financial institution where the campaign bank account is located and the person(s) authorized to obtain bank records. NAME OF FINANCIAL INSTITUTION AND PERSON(S) AUTHORIZED TO OBTAIN BANK RECORDS US Bank AREA CODE/PHONE 800 872-2657 BANK ACCOUNT NUMBER 157532380084 ADDRESS OF FINANCIAL INSTITUTION 393 W Foothill Blvd 4. Type of Committee Complete the applicable sections. Controlled Committee CITY Claremont • 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. STATE CA • 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 ZIP CODE 91711 Corey Calaycay City Council Member 2024 Nonpartisan J 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(5) 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 (October/2023) FPPC Advice: advice(cafppc.ca.gov (866/275-3772) www.fpoc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE COMMITTEE NAME corey Calaycay for Claremont City Council 2024 I.D. NUMBER 1464043 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: ❑ CITY Committee ❑ COUNTY Committee ❑ 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 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 (October/2023) FPPC Advice: advice@fppc.ca.gov (866/275-3772) www.fppc.ca.gov