410 Amendment tatement of Organization
Recipient Committee
Statement Type [] Initial
Not yet qualifled [] or
/
Date qualified as COmmittee
1. Committee Information
Type or print in ink
~Amendment
List I.D. number:
9 ,ob ,o\
Date qualified as COmmittee
(If applicable)
NAME OF COMMWrEE
STREET ADDRESS (NO P,O, BOX)
CITY STATE ZiP CODE
MAiLiN ~-~A~D pD~ ~ ~j F~D~F?E~NT, CA
[] Termination - See P~r~ 5
List I.D. number:
Date of Termination
~Stamp
OPTIONAL: FAX / E-MAIL ADDRESS
COUNTY OF DOMICILE
Sav - o C bra Co
2. Treasurer and Other Principal Officers
STATEMENT OF ORGANIZATION
I
NAMe, OF TREASURER
109 ¢iromm -c. Rd
AREA CODE/PHON E
ICOUNTY WHERE COMMITI-EE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
NAME OF ASSISTANT TREASURER. IF ANY
Attach additional information on appropriately labeled continuation sheets.
ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S). IF APPLICABLE
MAILING ADDRESS
CITY STATE ZiP CODE 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 her~n is true and complete. I certify under penalty of
perjury under the laws of the State of California that the foregoing is true and co~.~Executed on q- ] ~) ~DA~[ By //// , 1 '~T2EJ~OF TREAS ~STANT TREASURER
Executedon q-/O--DATE / By :/"~'""~ GN~A<~E~OF~ON~T L~ OFF 0 O ,C~NOID~TE. ORSTATE~F.~SUREPROPO,ENtS ,CEH L ER
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE. OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONi=NT
FPPC Form 410 (Janl01)
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