410 Statement of Organization Recipient Committee - Initial Qualified stamped by SOS noting IDStatement of Organization
Recipient Committee
Statement Type X Initial
Not yet qualified ❑ or
07 I 30 1 14
Date qualified as committee
1. Committee Information
Type or print in ink
❑ Annendment
List I.D. number:
�J
Date qualified as committee
(If applicable)
E] Termination — See Part 5
List I .D. number: in
Date of Termi nation
NAME OF COMMITTEE
Robert McCoy for Council 2014
STREET ADDRESS (NO PO. BOX)
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 continuation sheets
STATEMENT OF ORGANIZATION
Date Stamp
FILED Mr WM %ly W L
office of the Secretary of St -a D
of the Stag of Caiifortlia _
AUG 0 8 2014 AIiG 2 9 2014
2. Treasurer and Other Principal Officers
NAME OF TREASURER
Blossom McCoy
STREET ADDRESS
NAME OF ASSISTANT TREASURER. IF ANY
STREET ADDRESS
CITY STATE ZIP CODE AREA CODE /PHONE
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE
MAILING ADDRESS
STATE .ZIP CODE AREA CODE /PHONE
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
Executed on August 5, 2014 By
Executed on August 5, 2014
DATE
Executed on
Executed on
DATE
By
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
SIGNATURE OF CONTROLLING OFPICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (Janl01)
FPPC Toll -Free Heinlino: 666 /ASK -FPPC
K
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
Robert McCoy for Council 2014
• All committees must list the Financial institution where the ram paign bank account is located.
NAME OF FINANrIALINSTITLITION
Bank of America
AREA CODE/ PHONE
(
STATE ZIPCODE
I.D. NUMBER
ADDRESS
4, Type of Committee Complete the applicable sections.
Controlled Committee:.
• 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 "nonpartisan."
• 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 CAN DIDATE /OFI=ICFHOLDER /STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR Or ELECTION PARTY
® Nonpartisan
Robert McCoy City Council 2014
❑ Nonpartisan
Primarily formed to support or oppose specific candidates or measures in a single election. List below:
Primarily Formed Committee;
CANDIDATES) NAME OR MEASURE(S) FULL TITLE OCLUDE BALLOT NO, OR LETTER)
CANDIDATE {S) OrnCE SOUGHT OR HELD OR MEASURE(S) lIJRISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
CIAKK ONE
SUPPORT I OPPCEE
SU PE
IN
FPPC Form 410 (Dec /2012)
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