410 Amendment tatement of Organization
Recipient Committee
Statement Type ^ initial
Not yet qualified ^ or
~~
Date qualified as committee
Type or print in ink
Amendment
Ust I.D. number:
# 13003$3
~~~
Date qualified as committee
(If applicable)
^ Termination -See Part 5 ,
List LD. number: - -
~~
Date of Termination
1. Committee Information
NAME OF COMMITTEE
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STREETADDRESS (NO P.O. BOX)
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CITY STATE ZIP CODE AREA CODE/PHONE
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MAILING ADDRESS (IF DIFFERENT)
OPTIONAL: FAX / E-MAILADDRESS
Date Stamp ~
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2. Treasurer and Other Principal Officers
OF ORGANIZATION
NAME OF TREASURER
STREETADDRESS (NO P.O. BOX)
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CITY STATE ZIP CODE AREA CODElPHONE
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NAME OF A SISTANT TREASURER, IF ANY
STREETADDRESS (NO P.O. BOX)
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CITY STATE ZIP CODE AREA CODE/PHONE
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NAME OF PRINCIPAL OFFICER(S)
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE STREETADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
Attach additional information on appropriately labeled continuation sheets.
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 f the State of California that the foregoing is true and correct. _
Executed on ~ ~ C By ~
DATE SIGNATURE OF TREASURER OR ASSISTANT TREASURER
Executed on ~ ~ "~ ~ ~ By ~ ~~ fL
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE. OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (June/09)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
Statement Of OrganlZatlOn STATEMENT OF ORGANIZATION
Recipient Committee • ' ~ ~
INSTRUCTIONS ON REVERSE
Page 2
COM~MtI,T,TEE N'A`ME t ~+ / / n ^ q I.D. NUMBER b
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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 MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IFAPPLICABLE) YEAR OF ELECTION PARTY
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'C ~ SR h rI ~rD /
C f ~" ~o G. ve ~ ~~ f 2 U O ~ ~ Non-Partisan
^ Non-Partisan
• List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NA~~ 1F~ ~ CI,A,L~~hITUTI~~ ~~ / AREA CODE/PHON~ c~ ^ ~ oU u BANK ACCOUNT NUMBER
ADDRESS CITY STATE ZIP CODE
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- . 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
FPPC Form 410 (Junel09)
FPPC Toll-Free Helpline: 866/ASK-FPPC (8661275-3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
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4. Type of Committee
Cf~v C'•~•a~
(Continued)
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
^ CITY Committee ^ COUNTY Committee ^ STATE Committee
2 00
STATEMENT OF ORGANIZATION
Page 3
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PROVIDE BRIEF DESCRIPTION OF ACTIVITY
List additional sponsors on an attachment.
NAME OF SPONSOR
STREET
GROUP OR AFFILIATION OF SPONSOR
LI I Y
LIP CODt
^ _J~
Date qualified
5. TerminatlOn RegUlrementS 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 Form 410 (Junel09)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275772)