410 Termination tatement of Organization
Recipient Committee
Statement Type
~ Initial
Notyetqualifetl ~ or
~~
Date qualified as committee
1. Committee Information
Type or print in ink
Q Amendment ~y Termination-See Part If i' Yrt g p
List I.D. number: `List I.D. number: YYY {- ~# ~G Y
# # 13~c3~~l
~ f ~~' .~ / o C ERTINO CITY C
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Date qualifed as committee Date of Termination
(If applicable)
2. Treasurer and Other Principal Officers
NAME OF COMMITTEE
STATEMENT OF ORGANIZATION
For
NAME OF TREASURER
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CNl~1~~ STREETADDRESS(NO P.O.BOX)
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STREETADDRESS (NO P.O.60X)
MAILINGAD~RESS (IF DIFFERENT)
i,iTr ,ir,^^°~ nocernn~iounniG
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OPTIONAL: FAXIE-MAILADDRESS
NAME OF PRINCIPAL OFFICER(S)
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE ISACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE STREETADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREACODEIPHONE
Attach additional information on appropriately labeled continuation sheets
3. Verification
I have used all reasonable diligence in preparing this statement and to the best true and complete.
perjury under the laws of the State of California that the foregoing is true ar~' ^^~~°^'
Executed on % ' ! Sr ' N~ l (J gY
DA E
Executed on I - i ~ ' 'l D 1 t7 gy
DATE
Executed on
DATE
Executed on
DATE
I certify under penalty of
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
~~
FPPC Form 410 (June109)
FPPC Toll•Free Helpline: 8661ASK•FPPC (8661275.3712)
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
tatement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
t~L
4. Type Of Committee Complete the applicable sections.
Controlled Committee
2
13 c~~~~~ I
• 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 "non-partisan."
• 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 CANDIDATEIOFFICEHOLDERISTATEMEASURE PROPONENT (INCLUDE DISTRICT NUMBER IFAPPLICABLE) YEAR OF ELECTION PARTY
[~ Non-Partisan
t t'•~u i~1~ ~~ ~ ~ C h ~ ti C Ca,r, rtr I~~Zu ,,, ~ L ~~ t ~ c;.w i z L ~-GZy
Non-Partisan
• List the financial institution where the campaign bank account is located (controlled "candidate election' committees only)
NAME OF FINANCIAL INSTITUTION
ADDRESS
~R.~r
AREA CODEIPHONE
~~~-
STATE ZIP CODE
STATEMENT OF ORGANIZATION
~ ~~
CHECK ONE
FPPC form 410 (June109)
FPPC Toll•Free Helpline: 8661ASK•FPPC (8661275.3772)
Statement of Organization
Recipient Committee
STATEMENT OF ORGANIZATION
INSTRUCTIONS ON REVERSE
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Page 3
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4.Type of Committee (Continued)
" ~ ~ ~ Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
Q CITY Committee Q COUNTY Committee 0 STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
, , • , List additional sponsors on an attachment.
NAME Of SPONSOR
GROU P OR AFFILIATION OF SPONSOR
STREETADDRESS NO.ANDSTREET CITY STATE 21PCODE
, it , ,
~~~
Date qualified
5. TeIT111natl0n RegUlrementS By signing the verification, the treasurer, assistant treasurer antllor candidate, offceholtler, or proponent certify that all of the follovnng 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 Cotle Sections 89511-
89518,and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5.
FPPC Form 410 (June109)
FPPC Toll•Free Helpline: 8551ASK•FPPC (6661275.3772)