410 Amendment 1 tatement of Organization
Recipient Committee
Statement Type [] Initial
Not yet qualified [] or
Date qualified as committee
1. Committee Information
Type or print tn Ink
.~. Amendment List I.D. number:.
Date quelifi~:l es committee
NAME OF COMMITTEE
STREET ADDRESS (NO P.O. aox)
CITY STATE
MAILING ADDRESS (IF DIFFERENT)
ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX / EoMAIL ADDRESS
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
Atlach additional information on appropriately labeled continuation sheets.
[] Termination - See Part 5
List I.D. n umbe~.
I I
Date of Termination
Dale Stan~p _.T ' -.
2. Treasurer and Other Principal Officers
STATEMENT OF ORGANIZATION
For Official Use Only
NAME OF TREASURER
STREET ADDRESS
NAME OF ASSISTANT TREASURER, IF ANY
ZIP CODE AREA CODE/PHONE
STREET 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 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. /3/] ~ ,~ /
Executed onExeouted on q/~Z ~/~ [ q/~'- (~/0~ DATE 'By [~Y ~iSlG~~ ~/f//~"~' Sl~ TREASURER OR ASSISTANT TREASU RF..R
Executed on By
OATE SIGNATURE OF CONTROLLING OFFICEHOLOER. CANDIOATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLOER. CANDIDATE. OR STATE MF-ASUR~5 PROPONENT
FPPC Form 410 (Jard01)
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