410 Statement of Organization Recipient Committee – Initial Not Yet QualifiedStatement of Organization
Recipient Committee
Statement Type -Initial
(DAot yet qualified
or
Q Date qualified as committee
❑ Amendment ❑ Termination — See Part S
!—
Date qualified as committee Date of termination
I.D. Number
Committee Information
(if applicable)
NAME OF COMMITTEE
I
9
STREETADDRESS (NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
MAILING 'ADDRESS (IF DIFFERENT)
(
E-MAIL ADDRESS (REQUIRED) J FAX (OPTIONAL)
COUN OF DOMICILE I IURISD ION WHERE COMMITTEE IS ACTIVE
Attach additional information on appropriately labeled continuation sheets.
NAME OF TREASURER
STREET ADDRESS��.BOX)
Date Stamp
For Official Use Only
CITY STATE ZIP CODE AREA CODE/PHONE
NAME OF ASSISTANT TREASURER, IF ANY
ric -'sC-
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX)
CITY
STATE ZIP CODE
AREA CODE/PHONE
1, -"Verification:.:
1 have used all reasonable diligence in preparing this statement 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 State
ASURE 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(February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
f
Statement of Organization CALIFORNIA
Recipient Committee e ; I, 41 J
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME ] �- r`,'• _`- j f f, _ I'j I.D. NUMBER
f
All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA COOE(PHONE BANK ACCOUNT NUMBER
ADDRESS ,� CITY
f �-RE
I IAI E ZIP CODE
• 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." Stating "No parry preference" is acceptable.
• 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 YEAR OF PARTY
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) ELECTION
.i %
;�` `! y.`"7 c 5 `9 q f +y`�; r �' # f:
,L i,' .= L (_i' '�
SUPPORT
Nonpartisan
.�,y`
Partisan
❑
(list political party below)
d
. Y. i. i
f � 1 i
%
Nonpartisan
Partisan
(list political party below)
El
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
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME. (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
(o{A{1t C,0? If . e ? . Z
SUPPORT
OPPOSE
SUPPORT
E
OPPOSE
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
(o{A{1t C,0? If . e ? . Z
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee ❑ Political Party/Central Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
Sponsored Committee List additional sponsors on an attachment.
NAME OF SPONSOR
STREET ADDRESS NO. AND STREET
CITY
GROUP OR AFFILIATION OF SPONSOR
Page 3
I.D. NUMBER
STATE ZIP CODE AREA CODE/PHONE
Small Contributor Committee ❑
Date qualified
�. n'.R@ii Ulrement5 8y signing the verification; the treasurer assistant treasurer and/or candidate afficeholder, or prominent ceriTfy=that aft of the foADwing candfioiis 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.
Clear Page:. 1, Print
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (8661275-3772)
www.fppc.ca.gov
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