410 Statement of Organization Initial 3
Statement of Organization
Recipient Committee
Statement Type ~ Initial
Not yet qualified ^ or
,~~
05 /~ 2009
Date qualified as committee
Type or print in ink ~~\ ~ ~~`~
^ Amendment
List I.G. number:
~~_J
Date qualified as committee
(If applicable)
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 CODE/PHONE
Cupertino CA 95014 408-480-3902
MAILING ADDRESS (IF DIFFERENT)
OPTIONAL: FAX / E-MAIL ADDRESS
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
Santa Clara
Attach additional information on appropriately labeled conl;nuation sheets
2. Treasurer and Ot her Principal Officers
NAME OF TREASURER
Tamara Pow
STREET ADDRESS
21866 Wilson Court
CITY STATE ZIP CODE AREA CODE/PHONE
Cupertino CA 95014 408-441-7500
NAME OF ASSISTANT TREASURER, IF r1NY
Lan-Huong Ngo Dang
STREET' ADDRESS
10192 Park Circle West #1
CITY STATE ZIP CODE AREA CODE/PHONE
Cupertino CA 95014 ~,~~~~~~~ ... g q02
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 CODE/PHONE
Cupertino CA 95014 408-480-3902
3. Verification
I have used all reasonable diligence in preparing ttiis 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 a
Executed on 5,a~ ~a°Og By
DATE
Executed on ~~ f 2 A 1 ~D I By
DATE
Executed on
DATE
Executed on
DATE
By
SIGNATURE OF CONTROLLING OFFICEHOLDL-:R. CANDIDATE. OR STATE MEASURE PROPONENT
FPPC Form 410 (January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC (8661275-3772)
^ Termination -See Part 5 ire
List I.D. number:
Date Stamp
office n -;.;~, ,;;~setary of
r~atifosnta
JUN 0 1 2009
STATEMENT OF ORGANIZATION
ci a my
J U L 2 0 2009 ,
Da et of~ ation ~ t' ~~y~ ~ L_____
$eCretar~ of St UPERTINO CITY CL RK
By SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
tatement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Daniel Nguyen For City Council 2009
Pending
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 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 CANDIDATEIOFFICEHOLDER/STATE MEASUf2E PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
Daniel Nguyen
City Council
2009 ® Non-Partisan
I
I Non-Partisan
i
• List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
Wells Fargo 408-863-6100 9117557588
ADDRESS CITY STATE ZIP CODE
10260 S De Anza Blvd Cupertino CA 95014
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
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE
OPPOSE
FPPC Form 410 (January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
STATEMENT OF ORGANIZATION
Page 3
COMMITTEE NAME i v IVUM DCR
Daniel Nguyen For City Council 2009 Pending
4. Type of Committee (Continued)
• • • Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
^ CITY Committr~e ^ COUNTY Committee ^ STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
• • . - • List additional sponsors an an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE
• ^ _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 1/1/01.
5. Term i nation 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.
FPPC Form 410 (January/05)
FPPC Toll-Free Helpline: 866IASK-FPPC (866/275-3772)