410 Termination tatement of Organization
Recipient Committee
Statement Type [] Initial
Not yet qualified [] or
?~pe or print In Ink
[] Amendment
Ust I.D. numb6-:
I I I I
Date qualified as committee Date qualified as committee
1. Committee Information
NAME OF COMMi I ! I=E
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE
MAILING ADDRESS (IF DiFFEHI=NT}
AREA CODE/PHONE
'~ Termination - See Part
Ust I.D. number:
Date of Termina§on
STATEMENT OF ORGANIZATION
JP~'RTINO ~ CLEFIK I
2. Treasurer and Other Principal Officers
NAME OF TREASURER
STREET ADDi~E~:~
CITY STATE ZIP CODE
NAME OF ASSISTANT TREASURER, IF ANY
AR EA COD E/PHONE
~IK=I:I 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
OPTioNAL: FAX I E-MAIL ADDRESS
COUNTY OF DOMICILE
I COUNTY WHERE COMMii' I I::E IS ACTIVE IF DIFFERENT
~,~-r'~ ¢ L.,~,~, rT"ANCOU'm'OFDO"'C"E
Attach additional inforrnaifon on approp~fate~y labeled conlfnuaUon sheets.
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
perjmy under the laws of the State of California that the foregoing is true and correct.
Executed
7RF-ASURER
SIGNATURE OF CONTRO~.M ~"~/F'IcEHOLDER, CAJ~IDATE, OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROl. LING OFFICEHCX.DER. CANDIDATE, OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING OFFICEHOCDER, CANDIDATE. OR STATE MEASURE PROPONENT
FPPC Form 410 (Janl0t)
FPPC Toll-Free HelDIIne: 8661ASK-FPPC
tatement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
STATEMENT OF ORGANIZATION
Page 2
1.0, NUMBER
4. Type of Committee Complete the applicable sections.
· 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.
· List the political party with which each officeholder or candidate is affiliated or check "non-partisan.'
· If this committee acts jointly with another controlled committee, list the name add identification number of the other controlled Committee.
ELECTIVE OFFICE SOUGHT OR HELD
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
c~'W ~' C~./~/,.,'o 2..00 !
[] Non-Partisan
NAME OF FINANCIAL INSTITUTION i AREA CODE/PHONE
ADDRESS Cl~ STA~ ZIP CODE
Primarily foxed to support or oppose specific candidates or measures in a single eleclion. Ust below:.
CANDIDATE(S) NAME OR MEASURE(S) FUU. TITLE (INCLUDE BALLOT NO. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO CITY OR COt
FPPC Form 410 (Jan/01)
FPPC Toll-Free Helpllne: 8661ASK-FPPC