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1. Commiffee Info~ation 2. Treasurer and Other P~ncipal Officem
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3. Verification
I h~e u~ all mawna~e daig~ in pre~dng this s~te~nt a~ to the best ~ my ~o~ ~e in~Uon ~in~ heMn is tree and ~p~le. I ~i~ under p~al~ of
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FPPC Fo~ 410
~PC Toll~me He,Brim: B~A~K~PPC
Statement of Organization STATEMENT OF ORC-,,VIIZATION
Recipient Committee CALIFORNIA 41 0
FORM
INSTRUCTIOt~ ON REVERSE Pig/2
I
COMMITTEE N~ · I.D. NUMBER
4. Type of Committee Complete the applk:eble sections.
Controlled Committee
· Lisl the name of ssch conlrolling officeholder, candidate, or state measure proponent. If candidate or officeholder controlled, also list the elective office sought or held, and
dislrict number, if any, ,=nd the year of the election.
· Ust Ih. polilicM party with which e=ch officeholder or candidate Is effiltated or check "non-partisan."
· If this commlltee acta joinlly with another conlrolled committee, list the name and identification number of the olher controlled committee.
ELECTIVE OFFICE SOUGHT OR HELl)
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
[] No~.PaAl~an
[] Non-Padiman
· List the financial institution where the campaign bank m~ount is located (controlled "candidate election" committees only)
NAME OF FIHANCIAL II~TITUTION AREACOOE/PHONE BANK ACCOUNT NUMBER
ADORESS CITY STATE ZIP CODE
Primarily Formed Committee Pdmadly formed to support or oppose speclfic candidates or measures ln a sl~le ~n. Ustbelow:
CANOIDATE(8) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) CANI)ICATE(S) OFFICE 8OUGHT OR HELl) OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO.. CITY OR COUNTY, AS APPt. ICAELE) CHECK ONE
FPPC Form 410 (Jan/01)
FPPC Toll-Frae Helpll,t: 8~/ASK-FPPC
Statement of Organization STATEMENT OF ORGANIZATION
Recipient Committee CALIFORNIA 4 1 0
FORM
~STRUCTIONS ~ REVERSE PIIgll
COMMITTEE NAME I.O, NUMBER
4. Type of Committee
General Purpose Committee Nolformedtosuppo~loropposespectflccandldatesor measoresln-$1ngleMecllon. Check only one box:
r'! crrY Comm~lee [] COUNTY CommRtee [] STATE Commlltee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
St~onsored Committee List additional sponsom on Im attachment.
NAME OF SPONSOR I,~usTRY GROUP OR AFFILIATION OF SPONSOR
I
STREET ADDRESS HO. AND STREET CITY STATE ZIP COOE
Small Contributor Committee E] I ~.__ Checkboxandprovldethedatelhlscommltteequal~mdasasmallcontribut~m~t~. Ifthecommltteequalifled-,llllmall
Date qualilled conlHbutor committee on January 1,2001, enter 111/01.
5. Termination Requireme nte By.~gr~ng ~ ~, the tn.,.umr, a.sblan/Imemsror and/or candidate, ofllceholdor, or proponent certify that .11 al' the following rendition, have been met:
· This committee has ceased to receive conlributions and make expenditures;
· This committee does not anticipate receiving contributions or making expenditures in the future;
· This committee has eliminated or has no Intention or ability to discharge all debts, loans received, and other obligations;
· This committee has no surplus funds; and
· This committee has filed all campaign statements required by the Political Reform Act disclosing all reportable transactions.
-- There are restrictions on the disposition of surplus campaign funds held by elected officers who are leaving office end by defeated cendldatas. Refer to
Government Code Section 89519.
-- Additional filing obligations will be incurred if, after terminating, the committee receives or spends any funds, or receives the forgiveness of a loan,
repayments of loans made to others, or any other receipts.
FPPC Form 410 (Jan/01)
FPPC Toll-Free Help#ne: 8E6/AaK-FPPC