410 Statement of Organization Not Yet Qualified (Courtesy filing)Date qualified as committee
1. Committee Information
NAME OF COMMITTEE
Date qualified as committee
(it applicable)
(01
A
STREET ADDRESS (NO P.O. BOX)
----------
CITY STATE ZIP CODE AREA CODE/PHONE
0
MAILING ADDRES(IF DIFFERENT)
i(v ct
OPTIONAL: FAX E-MAIL ADDRESS
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT A0 0
THAN COUNTY OF DOMICILE
CITY STATE ZIP CODE AREA CODE/PHONE
Attach additional information on appropriately labeled continuation sheets. S'
------------ now
3. Verification
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 California that the foregoing is true and correct.
Executed on �. ,By
DATE
OR STATE MEASURE PROPONENT
-1 ---------- - - 1. A BOWEN
Date of Termination
acrewry 01 OLaL=
2. Treasurer and Other Principal Officers
--- - - - - ----- - ---------------
Executed on
DATE
Executed on
DATE
By
NAME OF TREASURER
AAdwrxc iAq- C 6L,, �`j ' 14FREETADDRESS (NO P.0. BOX)
ZIP CODE AREA CODE/PHONE
<i
CA
NAME OF ASSISTANT TREA8URER, IF ANY — ------------ ---- -
A YK "to
STATE ZIP CODE
CA
NAME OF IRINOPAL OFFICER(S)
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
. FPPC Form 410 (April/2011)
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/276-3772)
II J
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Statement of Organization STATEMENT OF ORGANIZATION
RecipientCommittee
INSTRUCTIONS ON REVERSE WARIORMONNOM
Page 3
- COMMITTEE NAME
I.D. NUMBER
L-5 -ICW4- PAC
4. Type of Committee (Continued)
• R - Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee ❑ COUNTY Committee STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
c • i
List additional sponsors on an attachment.
NAME OF SPONSOR (INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREETADDRESS NO. AND STREET
CITY
STATE ZIP CODE
Date qualified
5. Termination Requirements By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or proponent certify that 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 norm 410 (April/2011)
FPPC Toll -Free Helpline: 866/ASK-FPPC (866/275-3772)
� si ra
n
Statement of Organization
Recipient Committee
Statement Type Initial
Not yet qualified !or
Type or print in ink
❑ Amendment
List ID. number:
Date qualified as committee Date qualified as committee
(If applicable)
in V
El Termination — See Part 5
List I.D. number:
Date of Termination
Rejected: e<.~
Returned; STATEMENT OF ORGANIZATION
office of the Secretary pf &For
of the State of California Official Use Only
"'ECEIVED AND FliMMED
the off is of the Secrotary Of StatO
secretary of Stat of the State ttf- CaR{fQrnf
1. Committee Information 2. Treasurer and Other Principal Officers
NAME OF COMMITTEE ,/701
����,�wc�p,�r.��. NAME OF TREASURER DEBRA
��.�' P
�i'C;� n��rI�t�of =te
�✓��� STREET (NO P.0. BOX)
Poo/
A F" ?,VA e
p \•�
CITY STATE ZIP CODE AREA CODE/PHONE j!� NAME OF ASSISTANT TREASURER, IF ANY
4\
�`� V (''�� A� ���`�� � ,* � STREETADDRESS ( O P.O. BOX)
MAILINGADDRES (IF DIFFERENT)
// r4f,,�A
NAME OF PRINCIPAL OFFICER(S)
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT ,.
THAN COUNTY OF DOMICILE STREET ADDRESS (NO P.O. BOX)
SC\ (X\f -o.,
Attach additional information on appropriately labeled continuation 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 true and complete. I certify under penalty of
perjury under the laws of the State of California that the foregoing is true and correct.
CANDIDATE, OR STATE MEASURE PROPONENT
Executed on
DATE
Executed on
DATE
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
SIG AT RE OF CONTROLLING OFF CEO DER, CA DI DATE, OR STATE MEA8URE PROPONENT
FPPC Form 410 (April/2011)
FPPC Toll•Froe Helplino: 866/ASK-FPPC (866/276-3772)
" . .
Statement of Organization ' STATEMENT OFORGANIZATION
Recipient Committee
IEEEEW� "-i's
INSTRUCTIONS ON REVERSE
Page 3
COMMITTEE NAME I.D. NUMBER
Ell I
4.T«pe of Committee (Continued)
iMMA Not formed msupport moppose specific candidates mmeasures musingle election. Check only one bo'X:
Fl CITY Committee COUNTY Committee WSTATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
AVN Vul fV I C C& IsA +Ae- C0mt-fik-i41'*V.'
To Lk 0 -P f) �rli Vi5 is
-- -- --- ---
List additional sponsors on an attachment,
_
NAME OF SPONSOR JINDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS NO, AND STREET CITY STATE ZIP CODE
-'
'
Fl
Date qualified
5^Termination Re0u|rementS By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or proponent certify that 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 nosurplus 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 defeatedoand|detea. Ref rto
Government Code Section 8H518.
� Leftover funds of ballot measure committees may be used for political, legislative or governmental purposes under Government Code Seotione8R511 ~
88518.and are subject toElections Code Section 18GO0and FPPCRegulation 18521.5.
FppCForm 41
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