410 Amendment tatemen! 'Organization
Re61pient Committee
Statement Type r'] Initial
Not yet q~illed
I I
Dale qualiFmd as (:of~'nittee
1. Committee Information
Type or print In Ink
I~ Amendment
List I.D. numbe~.
NAME OF COMMITTEE
STREET ADORESS {140 P.O. BOX)
I~lN6 ADORE$S (1~ DIFFERENT)
OPTIOn: FAX I E4~,'~ORE$S
STATE ZiP CODE AREA CODE/PHONE
COUNTY OF DOMICILE
ICOUNTY WHERE COMMITTEE[ IS ACTIVE IF DII-I-I=~.ENT
THAN COUNTY OF DOMICILE
Attach ~'dt6onat information on appropriately labeled continuaJfon sheets.
r-J Termination - See Part 5
Ust I.D. number:.
STATEMENT OF .tANIZATION
Dale Stamp · It~ , .
Date of Ten~ina0on I
2. Treasurer and Other Principal Officers
S¥~EET ADDRES~
lo,Coz IWi ~-¢.l,J.~o,J A
CITY STATE ZiP CODE
NAME OF ASSISTANT TREASURER, IF ANY
AREA CODE/PHONE
STREET ADDRESS
CITY ~i I~I t: ZiP CODE AREA CODE/PHONE
NAME A,NO POSt'T~OH OF OTHER PRINCIPAl. OF FICER{S). IF APPUC, a~LE
MAIMNG ADORESS
CITY STATE ZIP CODE AREA cooE/PHON E
3. Verification
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herein is Irue and complete. I certify under penalty
perjury under the laws of the State of California that the foregoing is tree and correct.
Executed m ~Y
/
~;, ,SIGNATURE O¢~I~EASUR ER OR ASSISTANT TREASURER
SIGNATU~ OF CO~i~ROI~J.NIG O~FICEHOL~ER, CANOIDATE. OR STATE ME~SURE pROPONEN
SIGNATURE OF CONTROLLING OFFICEHOLDER, CAt4OIOATE. OR STATE ~RE pROPONENT
SIGNATURE OF CONTROLLING OFFICEHOCDER. CANDIDATE. OR STATE MEASURE PROPONENT
FPPC Form 410 (danl01)
FPPC Toll-Free Helpllne: 866/ASK-FPPC
, tater~ent of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
~[ NAME
4. Type of Committee compete the applicable sections.
SI'ATEMENT OF ORGANIZATION
· L~t ~ ~me of ea~ ~n~oll~ o~o~er, ~idate, ~ s~te measure pm~n~t.
d~t nu~r, ~ ~Y, a~ ~e y~r of ~
· L~t ~e ~ifi~l pa~ ~ wh~h ea~ o~lder or ~ldate is affiliat~ or ch~k 'non-~san."
· I~ ~is ~mmiEee a~ ~in~y ~ ano~er ~n~lled ~mmi~ee, list ~e name and ~enfi~n numar of ~e o~er ~n~olled ~mm~ee.
ELE~ OFFICE S~ OR HE~ Y~ OF ELECTION
()~UDE DIST~T ~MBER IF ~)
If candidate or officeholder controlled, also list the elective ofllce sought or held, and
pARTY
· List the linanctal institution where the campaign bank account is located (controlled"candidate election' committees only)
NAME OF FINANCIAl. INSTI'IUTION
'Po~u~y ~^V/~ ~,~ Lo~ ^ss~o~-~o,o [(.q~)-~3 ,5'~-'o L J ~ ~0 I~j/~'/'
CITY STATE ZIP CODE
ADDRESS
'''l'/liil~llltjl~i~'lliir''i'l[~liillllli{''~'-j Pdmarily formed to support or opflose speci§c candidates o~, measures in a single e)ectJon' listbelow:
CANDIDATE(S) OFFICE soUGHT OR HELD OR MEASURE(S) JURISDICTION
CANDIDATE(S) NAME OR MEASURE(S} FULL TITLE (INCLUDE BALLOT NO. OR LET[ER) (INCLUDE DISTRICT HO., CiTY OR COUNTY. AS APPUCABLE} ~
FPPC ' ,~ 410 (Jard01)
FPPC Toll-Free Helplh. .66~ASK-FPPC