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410 Amendment tatement of Organization ~.~ Recipient Committee Statement Type ^ Initial Not yet qualified ^ or _1_J Date qualified as committee Type or print in ink Amendment List I.D. number: # 1318643 05 /~ 2009 Date qualified as committee (If applicable) ^ Termination -See Part 5 List I.D. number: _,J_J Date of Termination Date Stamp 44fi y~ffi R C of >n~. .:;:{ :~;a oSfice ., O~ I~; 1 ~ 1_~'Oc I~~+ -. ~. ~ ~; .~ F ~ :; :gym .~ ~... 1. Committee Information NAME OF COMMITTEE Daniel Nguyen For City Council 2009 STREET ADDRESS (NO P.O. BOX) 10192 Park Circle West #1 CITY STATE ZIP CODE AREA CODElPHONE Cupertino CA 95014 408-480-3902 MAILING ADDRESS (IF DIFFERENT) OPTIONAL: FAX! E-MAIL ADDRESS COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS AC71VE IF DIFFERENT THAN COUNTY OF DOMICILE Santa Clara __ Attach additional information on appropriately labeled continuation sheets. 2. Treasurer and Othe8 STATEMENT OF ORGANIZATION ~' , ' o ICI s nl J U L - 9 2009 ~UPERTINO CITY CL RK NAME OF TREASURER Kelley Nguyen STREET ADDRESS 10192 Park Circle West #1 CITY STATE ZIP CODE AREA CODEIPHONE Cupertino CA 95014 408-480-3902 NAME OF ASSISTANT TREASURER, IF ANY Huong Dang STREET ADDRESS 10192 Park Circle West #1 cTeTG ~tv r.C1nF AREA CODE/PHONE Giir ,. ., .._ _ ---- Cupertino CA 95014 408-480-3902 NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S); IF APPLICABLE Daniel Nguyen, Candidate MAILING ADDRESS 10192 Park Circle West #1 CITY STATE ZIP CODE AREA CODElPHONE Cupertino CA 95014 408-480-3902 3. Verification I have used all reasonable diligence in preparing this statement and to the best of my knowledge the info ation containe erein is true and complete. I certify under penalty of perjury under the la (w}s of th/e Statee of California that the foregoing is true and correct. ~~~- Executed on v ~ ` ~' °~©~ By 4GNATUR~ OFD- OR ASSISTANT TREASURER Executed on ~ o ~ ~ ~ ~~~ By ATE SIGNATURE OF LING OFF HOLDER, DIDATE, OR STATE MEASURE PROPONENT Executed on DATE Executed on DATE By SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT By SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT FPPC Form 410 (January/OS) FPPC Toll-Free Helpline: 866/ASK-FPPC (8661275-3772) tatement of Organization Recipient Committee INSTRUCTIONS ON REVERSE STATEMENT OF ORGANIZATION COMMITTEE NAME Daniel Nauven For City Council 2009 I.D. N 4. Type of Committee Complete the applicable sections. ~ -. • 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 parry 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. NAME OF CANDIDATElOFFICEHOLDERISTATEMEASURE PROPONENT Daniel Nguyen ELECTIVE OFFICE SOUGHT OR HELD (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY City Council 2009 Non-Partisan • List the financial institution where the campaign bank account is located (controlled "candidate election" committees only) NAME OF FINANCIAL INSTITUTION Wells Farao ADDRESS 10260 S De Anza Blvd AREA CODE/PHONE 408-863-6100 CITY Cupertino BANK ACCOUNT NUMBER 9117557588 STATE ZIP CODE CA 95014 . ~ , ~ Primarily formed to support or oppose specific candidates or measures in a single election. List below: CANDIDATE(S) NAME OR MEASURE(S) FULLTITLE (INCLUDE BALLOT NO. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) ~ Non-Partisan CHECK ONE )RT OPPOSE FPPC Form 410 {Januaryl05) FPPC Toll-Free Helpline: 8661ASK-FPPC (8661275-3772} Statement of Organization Recipient Committee INSTRUCTIONS ON REVERSE STATEMENT OF ORGANIZATION I.D. NUMBER Daniel Nguyen For City Council 2009 4. Type of Committee (Continued) .. Not formed to support or oppose specific candidates or measures in a single election. Check only one box: ^ CtTY Committee ^ COUNTY Committee ^ STATE Committee PROVIDE BRIEF DESCRIPTION OF ACTIVITY • • . - . . List additional sponsors on an attachment. NAME OF SPONSOR USTRY GROUP OR AFFILIATION OF SPONSOR STREET ADDRESS NO. AND STREET cm STATE LII tGUUt • • ^ _~_J Check box and provide the date this committee qualified as a small contributor committee- If the committee qualified as a Date qualified small contributor committee on January 1, 2001, enter 1 /1101. S. Termination Requirements By signing the verification, the treasurer, assistant treasurerandlorcandidate,officeholder, or proponentoertifythatallofthefollowingconditionshavebeenmet: • 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 alt 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. FPPC Form 410 (Januaryl05) FPPC Toll-Free Helpline: 866/ASK-FPPC (866!275-3772)