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410 Statement of Organization Recipient Committee - Amendment '011W7 J a Statement of Organization Date Stamp CALIFORNIA 410 Recipient Committee RECEIVED AND FILED FORM Statement Type 0 Initial ® Amendment 0 Termination—See Part 5 in tie office of the Secretary of State llkr: 'd. etSnty of the State of California List I.D.number: List I.D.number: Not yet qualified CI or 1299673 MAY 12 2016 MAY 2 4 2016 a n / /___ ____t___/_ _t___/_____ CUPERTINO CITY CLERK Date qualified as committee Date qualified as committee Date of Termination (If applicable) 1. Committee Information 2. Treasurer and Other Principal Officers NAME OF COMMITTEE NAME OF TREASURER Cupertino Chamber PAC Andrew Walters STREET ADDRESS INO P.O.BOX) STREET ADDRESS(NO P.O.Box) CITY STATE ZIP CODE AREA CODE/PHONE CITY STATE ZIP CODE AREA CODE/PHONE MAILING ADDRESS(IF DIFFERENT) NAME OF ASSISTANT TREASURER,IF ANY FAX/E-MAIL ADDRESS STREET ADDRESS(NO P.O.BOX) COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE ISACTVE CITY STATE ZIP CODE AREA CODE/P HONE NAME OF PRINCIPAL OFFICERS) Richard Abdalah STREET ADDRESS(NO P.O.BOX) Attach additional information on appropriately labeled continuation sheets. CITY STATE ZIP CODE AREA CODE/P HONE 3. Verification I have used all reasonable diligence in preparing this r tement and to the best of my knowledge the information contained herein is true and complete. I certify under penalty of perjury under the laws.of the DATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT Executed on By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT Executed on By DATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,OR STATE MEASURE PROPONENT FPPC Form 410(Dec/2012) FPPC Advice:advice@fppc.ca.gov(866/275-3772) www.fppc.ca.gov Statement of Organization CALIFORNIA Recipient Committee FORM 41 0 INSTRUCTIONS ON REVERSE Page 2 COMMRTEE NAME I.D.NUMBER Cupertino Chamber PAC 1299673 • All committees must list the financial institution where the campaign bank account is located. NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER Bank of the West ADDRESS CITY STATE ZIP CODE 44TType 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"nonpartisan." • If this committee acts jointly with another controlled committee,list the name and 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 ❑ Nonpartisan ❑ Nonpartisan Primarily Formed Committee Primarily formed to support or oppose specific candidates or measures in a single election. List below: CANDIDATE(S)NAME OR MEASURE(S)FULL TITLE(INCLUDE BALLOT NO,OR LETTER) CANDIDATE(S)OFFICE SOUGHT OR HELD OR MEASURE(S)JURISDICTION (INCLUDE DISTRICT NO.,CITY OR COUNTY,AS APPLICABLE) CHECK ONE SUPPORT OPPOSE ❑ ❑ TIfPDRj DeoncC FPPC Form 410(Dec/2012) FPPC Advice:advice@fppc.ca.gov(866/275-3772) www.fppc.ca.gov • Statement of Organization CALIFORNIA Recipient Committee FORM 410 INSTRUCTIONS ON REVERSE Page 3 COMMITTEE NAME I.D.NUMBER Cupertino Chamber PAC 1299673 4.Type of Committee (Continued) General Purpose Committee Not formed to support or oppose specific candidates or measures in a single election. Check only one box: 0 CITY Committee 0 COUNTY Committee©.STATE Committee PROVIDE BRIEF DESCRIPTION OF ACTIVITY To support local and statewide candidates Sponsored Committee List additional sponsors on an attachment. NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR Cupertino Chamber of Commerce Chamber of Commerce STREET ADDRESS NO.AND STREET CITY STATE ZIP CODE Small Contributor Committee —�—� Date qualified 5.Termination Requirements By signing the verification,the treasurer,assistant treasurer and/or candidate,officeholder,or proponent certifythat 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. -- 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(Dec/2012) FPPC Advice:advice@fppc.ca.gov(866/275-3772) www.fppc.ca.gov