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410 Statement of Organization Recipient Committee - Amendment Reassign for 2016 Stamped by SOSSt-ateelient of Organization Recipient Committee Statement Type ❑ Initial © Amendment Notyetqualifed ❑ or List I.D. number: 1369332 ❑ Termination — See Part 5 List I.D. number- 4 Date umber- Date Stamp 2!1� slate of the ci10 JAN Z015 For Offival Use Only Date Received 07 30 /2014 / / JAIL 2 9 2015 Date qualified as committee Date qualified as committee Date of Termination IT applicable) 1 Committee informatigr, : 2. Treasurer �nd Other Prittci l �ffiters " ... NAME OF COMMITTEE NAME OF TREASURER Robert McCoy for Council 2016 Blossom McCoy STREET ADDRESS (NO P.O. BOXI STREET ADDRESS (No P.C. BOX) NAME OF ASSISTANT TREASURER, IF ANY STREET ADORESs(NO P.O. ROX) CITY STATE ZIP CODE AREA CODE /PHONE NAME OF PRINCIPAL OFFICFR(S) STREET Attach additional In(�orma ?ion on 7ppropriately labeled contrrruation sheets. ADDRESS IND P.O. RDX) CITY STATE ZIP CODE AREA CODE /PHONE 3. yeri cation i have used all reasonable diligence in preparing this statement and to the best of my knowledge the information contained herein is true and cornplete. I certify under penalty of perjury under the laws of the State TREASURER Executed on � By _ DATE SIGNATURE OF CONTROLLI NG OFF3C HOLDLR, CANDIDATE, OR STATE M EASUR L PR{)PDN ENT Executed on DATE Executed an DATE By By SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPON FPPC Form 410 (Dec /2412) FPPC Advice: advice @fppc.ca.gov (866/275 -3772) www.fppc.ca.gov Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE Page 2 cUMMiTTEE NAME I.D. NUMBER Robert McCoy for Council 2016 1369332 All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION Bank of America ADDRESS AREA CODE /PHONE ( STATE ZIPCODE 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 "nonpartisan" • If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee. NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY Robert McCoy City Council 2016 m Nonpartisan SUPPORT ❑ Nonpartisan Primarily formed to support or oppose specific candidates or measures in a single election. List below: CAND[DATE(S) NAME OR MEASURE(5) FULL, TITLE (INCLUDE BALLOT NO.OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURES) JURISDICTION {INCLUDE D15TRICT NO., CITY OR COUNTY, AS APPLICABLE) - CHECK ONE FPPCForm 410(Dec /2012) FPPC Advice: advice @fppc.ca.gov (866/275 -3772) www.fppc.ca.gov - SUPPORT 1:1 .OPPOSE EL SUPPORT OPPOSE FPPCForm 410(Dec /2012) FPPC Advice: advice @fppc.ca.gov (866/275 -3772) www.fppc.ca.gov