410 Statement of Organization Recipient Committee - Initial Not Yet Qualifed Stamped by SOS ��
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Statement of Organization � � � 4 � � R �s � °atesta"'P , • _ �
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Recipient Committee t
Statement T e � `�� � ���� � � �
Yp nitial � ❑ Amendment ❑ Termination—See Part 5 ��Ep������„o tne��' �� � �,��� '� �=F°��°�!use o�iy'
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Q Date qualified as committee —�—� � � ���� �� �'��� ` ��"� �' � ����
Date qualified as committee Date of termination �.� ��� �
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l. Committee lnformat�Qn :�:.: � • � 2. Treasurer and Other Pr�ncipal �fficers�'�������� �� �� �' ��� �
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NAME OF COMMITTEE NAME OF TREASURER �
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STREET
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MAII.ING ADORESS(IF DIFFERENT) � STREET ADDRE55(NO P.O.80X)
COUNTY OF DOMICILE JUftISDICTION WHERE COMMITTEE IS ACTIVE NAME OF PRINCIPAL OFFICER(5) .
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STREET ADDRE55(NO P.O.80x)
CITY STATE ZIP CODE AREA CODE/PHONE �
Attach additianal information on appropriately labeled continuation sheets. -
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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. I certify under
penalty of perjury under the laws of the State of
STATE MEASURE PROPONFNT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDEft,CANDIDATE,Oft STATE MEASUftE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROIIING OFFICEHOIDER,CANDIDATE,OR STATE MEASURE PROPONENT
FPPC Form A10(Februaryj2018)
FPPC Advice:advice@fppc.ca.gov(866/275-3772)
www.fppc.ca.gov
Statement of Organization � � � '
Recipient Committee � �
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INSTRUCTIONS ON REVERSE
Page 3
COMMITTEE NAME I.D.NUMBEft
�.,Type of Cgmmittee , {co�r���ea�, � ..' �: ,m:��:�:.. .,,.,.ti.,�.� �.�„�
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 PartyjCentral Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
List additional sponsors an an attachment.
NAME OF SPON50R INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREETADDRESS NO.ANDSTREET CITV STATE ZIPCODE AREACODE/PHONE
e � t t t ❑ /
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Date qualifl.ed
�.�@Ct7ltflatlOFl �@C�UII'@t71Et1�5 BysCgningtheverification,thetreasurer,assistanttreasureeandforcandidate,afficehQlder,orpropQnent�eriify#hatallofihe,follawangconditionshavepeenm�t,:;�
• 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(February/2018�
Clear Page Print� FPPC Advice:advice@fppc.ca.gov(866J275-3772)
www.fppc.ca.gov