410 Organization Recipient Committee
Statement of Organization
Recipient Committee
Type or print in ink
Statement Type
Mlnitial
Not yet qualified [!t'or
o Amendment
List I.D. number:
o Termination - See Part
List 1.0. number:
JAN 3 0 2007
#
#
-'-'-
Date qualified as committee
-' 1
Date qualified as committee
(If applicable)
-'-'-
Date of Termination
1. Committee Information
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Attach additional information on appropriately labeled continuation sheets.
STATEMENT OF ORGANIZATION
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2. Treasurer and Other Principal Officers
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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
perjury under the laws of the State of California that the foregoing is true and correct
I-~~ -Ol
DATE
Executed on
By
Executed on By
DATE
Executed on By
DATE
Executed on By
OATE
I certify under penalty of
~
SIGNATURE OF TREASURER OR ASSISTANT TREASURER
V~
SIGNATURE OF CONTROLLING OFFICEHOLDER CANDIDAT R STATE MEASURE PROPONENT
SIGNATURE OF CONTROlLING OFFICEHOLDER. CANDIDATE OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING OFFICEHOLDER. CANDIDATE. OR STATE MEASURE PROPONENT
FPPC Form 410 (January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
Statement of Organization
Recipient Committee
STATEMENT OF ORGANIZATION
'NSTRUCTIONS Oil. REVi:RSE
CALIFORNIA 410
FORM
CO\i1M!TT=E NAVE
61t.-$.efJ-1
f/J()/VG
! C NUMBER
FrJ/Z..
LI7f {OV /IIel L
4. Type of Committee Complete the applicable sections
Controlled Committee
· 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 and identification number of the other controlled committee.
NAME 0" CA \lC JA-E/O~F'CEHOLCi:R/S-A-E Mi:ASJRi: "ROPONEI\-
i:_i:CT!VE OF"ICi: SOUG'-lT OR -lELC
(I\lC~UCE o STRICT \lLM3i:R= A;:;"~'CA3_i:)
Yi:AR OF ELECTION
PAR7Y
6'/t.. /jf?~'7 ClfY U; 11/'f/t Ii. z~D7 ~ Non-Partisan
iJ 11'1/ Gr
o Non-Partisan
· List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
\lAVE OF FII\At\C AL t\STITL 70N
Wl5LLJ FN..C: (J /3,4/V1<
AREA COJ:::/PI-OI\E
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BAN<ACCOLt\ \lJMBER
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A::J::JRi:SS
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Primarily Formed Committee
Primarily formed to support or oppose specific candidates or measures in a single election List below:
CAI\C ::JATE(S) \lA VE OR MEASJRE(S: "JL_ TllLi: (II\C_LJ:: BA_LO- \10 OR _ETTER)
CAN::JICATE(S; OFF Ci: SOJGI-T OR 1-i:L::J OR Vi:ASLRi:(S) JJRIS::JICTlON
(INCLJCE ::JISTR C- t\O" C 7Y OR COLt\ -Y, AS A"P _ICAB_E)
CHECK ONE
I ,oeM" I oeM"
SUPPORT OPPOSE
FPPC Form 410 (January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
Statement of Organization
Recipient Committee
STATEMENT OF ORGANIZATION
\lSTRLiCTIONS 01\ REVERSE
CALIFORNIA 41 0
FORM
CO\i1M'TEE NAVE
6/{8fi'~1
LA ~/II ~
FO~
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4. Type of Committee (Continued)
General Purpose Committee
Not formed to support or oppose specific candidates Dr measures in a single election. Check Dnly one box:
!Sa CITY Committee 0 COUNTY Committee 0 STATE Committee
?ROVIc:lE 3R EF CESCRIP-'-'Ot\ OF ACT V -Y
Sponsored Committee
List additional sponsors on an attachment.
\lAVE OF S"OI\SOR
INCJS RV GROLP OR AFFILIATION 0.. SPO\lSOR
STRi:ET ACCRi:SS
NO At\D S-REi:-
C TV
S7ATE
Z"CODi:
Smaff Contriburor Committee
o -'-'_ Check box and provide the date this committee qualified as a small contributor committee. If the committee qualified as a
Date qualified small contributor committee on January 1,2001, enter 1/1/01
5. Term i nati on Req u i rem e n ts By signing the verification, the treasurer. assistant treasurer and/or candidate, officeholder or proponent certify that all of the following conditions have been met
. This committee has ceased to receive contributions 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 and by defeated candidates, Refer to
Government Code Section 89519
FPPC Form 410 (January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)