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HomeMy WebLinkAbout410 Amendment Statement of Organization Recipient Committee Statement Type ^ initial Not yel qualified ^ or ~-~ Date qualified as committee 1. Committee Information Type or print in ink I!d' Amendment Ust I.D. number: ^ Termination -See Part 5 List I.D. number: Data Stamp ~~.~~_ Date qualified as committee (If applicable) AUG 17 2009. STATEMENT OF ORGANIZATION _~~ e Use only Date of Termination ~ G~Ji'ERTINO CITY CLI~RK Z. Treasurer and Other Principal Officers NAME OF TREASURER STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE NAME OF COMMITTEE I,`, ~ l~ CS l-l iJ \~~~A lnA N 1 ~'~-, 2 C~ ~ C,\ l_. Z~ ~ STREETADDRESS (NO P.O. BOX) ~~ ~ '~ 1`x'1 ~ ~~ Lt ~y~.+ ~ •-~ Z CITY STATE ZIP CODE AREA CODE/PHONE CAP i/~=-n ,~ ~ e..~}- q~ 1 ~ c~©~-3 4~ - ~ L~ ( MAILING ADDRESS (IF DIFFERENT) OPTIONAL: FAX / E-MAILADDRESS 1~1~0.~,1^ t't COUNTY OF DOMICILE f--. /\ct COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT THAN COUNTY OF DOMICILE 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 statement and to the best of my knowledge the information contained herein is true and complete. I certify under penalty of perjury under tl~e laws of the State of California that the foregoing is true and correct. Executed on ~' ~ ~ 1 '°-q By DAT SI TURE OFTREASURER OR ASSISTANTTREASURER Executed on ~ ~ ~ ~ ~ 1 By DATE SIGNATU ROLLING OFFICEHOLDER, CANDIDATE. OR STATE MEASURE PROPONENT Executed on DATE Executed on DATE By . SIGNATURE OF CONTROLDNG OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT By SIGNATURE OF CONTROL NG O FICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT NAME OF ASSISTANT TREASURER, IF ANY STREET ADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE/PHONE NAME OF PRINCIPAL OFFICER(S) FPPC Form 410 (Junel09) FPPC Toll-Free Helpline: 866/ASK-FPPC (866/276-3772)