410 Statement of Organization Recipient Committee - Initial QualifiedStatement of Organization
Recipient Committee
Statement Type FXJ Initial
Not yet qualified ❑ or
07 ! 30 j_14
Date qualified as committee
Type or print in ink
D Amendment
List I.D. number:
Date qualified as committee
(Y applicable)
❑ Termination — See Part 5
List I D. number:
—^ 1J`
Date ofTerr ination
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tl V �5
Af i Irl Iii'
UPERTINC CITY CLEI
STATEMENT OF ORGANIZATION
For Official Use Only
#. Committee Information
2. Treasurer and Other Principal Officers
E ME OF
OF COMMITTEE
Robert McCoy for Council 2014
NAME OF TREASURER
Blossom McCoy
STREET ADDRESS
STREET ADDRESS (No i?O. BOX)
CA 95014 408- 320 -1469
MAILINGADDRESS (IF DIFFERENT)
STREET ADDRESS
OPTIONAL: FAX / E -MRIL ADDRESS
CITY STATE ZIP CODE
AREA CODEIPHONE
rc) bertmccoy4citycouncil@yahoo.CDm
COUNTY OF DOMICILE
NAME AND POSITION OF OTHER PRINCIPAT, OFFICER(S), IF APPLICABLE
COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY CF DOMICILE
Santa Clara
MAILING ADDRESS
Attach additional inforrratiorT on appropriately labeled continua;?bn sheets.
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
perjury under the laws of the State of California that the foregoing is true and correct.
true and complete.
s?
I certify under penalty of
Executed on August 5, 2014
DATE
Executed on August 5, 2014
Executed on
HATE
Executed on
DATE
By
SIGNATURE OF CONTRpLLING OFrICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
B/
SIGNATURE OF CONTRCLLINCy QFHCEHOLDER, CANDIDATE., OR STATE MFASUP,E PROPONENT
SIGNATURE OF CUNTROLLt G OFFICEHOLUER, CANDIDAE, OR S —E EASURE PROPONENT
FPPC Form 410 (Jan/01)
FPPC Toll -Free Helnline, 866/ASK-FPPC
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
CDUi MITTEE NAME FV.&2
Robert McCoy for Council 2014 I.Q. NUMBER
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCEALINSTTUTIC3N ARFACODE /PHONE BANK ACCOUNT NUMBER
Bank of America 1(
Auumt�� CITY SfA7E ZIP Co QE
4 •;Ty�se [#$. C[9.min ttee.. Complete the.appliCa:ble 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 "nonpartisan."
• If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee.
NAME OF CAN DIDAATE /OFFICEROLDER /STATE MEASURE PROPONENT
Robert McCoy
ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION
Council 1 2014
Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURE (S) FULL TITLE (1NCLUDL- BALLOT NO, OR LETTER)
CANDIDATE(S) OFFICE SOUGHT OR HELD OR NIEASURF(S) JURISDICTION
(INCLUDE DISTRICTNO„ CITY OR COUNTY, AS APPLICABLE)
PARTY
Nonpartisan
Nonpartisan
CHEEK ONE
;UPFORT OPPOSE
El EJ
SU P❑ O�
FPPC Form 410 (Dec /21112)
FPPC Advice: adviceC&fppc.ca.gov ($66/275 -3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
Robert McCoy for Council 2014
PROVIDE GRIEF DESCRIPTION CF ACTIVITY
NAME OFSPONSOR
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
® CITY Committee ❑ COUNTY Committee ❑ STATE Committee
- 2011M List additional sponsors on an attachment.
7 /
Date qua €Tfied
•
CITY
GROUP ORAFRL:AT3CN OF SPONSOR
This committee has ceased to receive contributions and make expenditures;
• This committee does not anticipate receiving contributions or making expenditures in the future;
STATE ZIP CODE
• 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.
Page 3
%D NUMBER
-- 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.
-- Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Sections 89511 - 89518, and are
subject to Elections Code Section 18680 and FPPC Regulation 18521,5.
FPPC Form 410(Bec /2012)
FPPC Advice: advice@fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov