410 Statement of Organization 07-12-2010 (2) Statement of Organization STATEMENT OF ORGANIZATION
Recipient Committee Type or print in ink Date Stamp � - ,
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Statement Type [] Initial 129 Amendment ❑Termination —See Part 5 For Official Use Only
Not yet qualified ❑ or List I.D. number: List I.D. number:
# (29q (PlS # JUL 12 2010
Date qualified as committee Date qualified as committee Date of Termination UPERTINO CITY CL K
(If applicable)
1. Committee Information 2. Treasurer and Other Principal Officer
NAME OF COMMITTEE NAME OF TREASURER
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P STREETADDRESS (NO P.O. BOX)
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STREETADDRESS (NO P.O. BOX) CITY STATE ZIP CODE AREA CODE /PHONE
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CITY STATE ZIP CODE AREA CODE /PHONE NAME OF ASSISTANT TREASURER, IF ANY
C_'J () C.,l ✓1 0 CA 1 �-o STREETADDRESS (NO P.O. BOX)
MAILING ADDRESS (IF DIFFERENT)
CITY STATE ZIP CODE AREA CODEIPHONE
OPTIONAL: FAX I E -MAIL ADDRESS
`lO q) ,Z S oZ — o Cp 3 O NAME OF PRINCIPAL OFFICER(S)
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT L ✓t C .
THAN COUNTY OF DOMICILE
STREET ADDRESS (NO P.O. BOX)
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CITY STATE ZIP CODE AREA CODE /PHONE
Attach additional information on appropriately labeled continuation sheets. n C 9s0 j y y08��SiZ 7d 5�
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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 - 7 ) U ( J By
7/ DATE
OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEH15LDER, CANDIDATE, OR STATE MEASURE PROPONEN
FPPC Form 410 (June /09)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (8661275 -3772)
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME } I.D. NUMBER
4. Type of Cott tutee Complete the applicable sections.
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• 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 CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
❑ Non- Partisan
❑ Non - Partisan
• List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANKACCOUNT NUMBER
ADDRESS CITY STATE ZIP CODE
�� . i • 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
SUPPORT OPPOSE
SUPPORT OPPOf
FPPC Form 410 (J
FPPC Toll-Free Helpline: 866 /ASK -FPPC (866/2'
Statement of Organization STATEMENT OF ORGANIZATION
Recipient Committee OR NIA
.-
INSTRUCTIONS ON REVERSE Page 3
COMMITTEE NAME I.D. NUMBER
( o p w V� ^,e> PAC_ ( z Mo 73
4. Type of Committee (Continued)
General Pur pose . 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
.. . . List additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
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STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE
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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 Form 410 (June /09)
FPPC Toll -Free Hetpline: 866 /ASK -FPPC (8661275 -3772)