410 Statement of Organization Recipient Committee - Initial not yet qualified Stamped by SOSU3
Statement of Organization
Recipient Committee
Statement Type ® Initial
Not yet qualified ® or
%Fr �3�Ib�15
❑ Amendment
List I.D. number:
❑ Termination — See Part 5
List I.D. number:
/---t - /-/ --/ /
Date qualified as committee Date qualified as committee Date of Termination
(If applicable)
+.. wmMIUM IFIT0rmanon 2.
NAME OF COMMITTEE
Committee supporting Cupertino Citizens' S"'5'ble. Crroah -, j')'t7-af7'V
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE /PHONE
Cupertino CA 95014
MAILING ADDRESS (IF DIFFERENT)
Cupertino, CA 95015 -
FAX / E -MAIL ADDRESS
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE 15 ACTIVE
Santa Clara Cupertino, CA
Attach additional information on appropriately labeled continuation sheets.
Date Stamp
Rf CEIVED AND FILE
in a office of the Secretary of St.
of the State of California
DEC .16 2015
JAN 1 1 2016
Treasurer and Other Principal Officers
� RK
NAME OF TREASURER
Xiaowen Wang
STREET ADDRESS (NO P.O. BOX)
I'll STATE ZIP CODE AREA CODE /PHONE
Cupertino CA 95014
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE /PHONE
NAME OF PRINCIPAL OFFICER(S)
Xiangchen Xu
STREET ADDRESS (NO P.O. BOX)
I'll STATE ZIP CODE AREA CODE /PHONE
Cupertino CA 95014
..::,Vert cation
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 12 / U- J 7 V (J
OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on
DATE
By
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410(Dec /2012)
FPPC Advice: adviceLWfppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
Statement of Organization CALIFORNIA
Recipient Committee . 4V IT 4
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME
I.D. NUMBER
Committee supporting Cupertino Citizens' S'ell[5�pe- Crow-r, /M fiiYf -)L)e
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE /PHONE BANK ACCOUNT NUMBER
pending ID #
ADDRESS
4. Type of Committee' Complete the applicable sections
Controlled Committee
Wkh'l
STATE ZIP CODE
• 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.
NAME OF CANDIDATE /OFFICEHOLDER /STATE MEASURE PROPONENT
ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
Primarily Formed Committee 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)
CANDIDATES) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
,�/
Cupertino Citizens' �5; j71e C7)j;JL✓ 1 �1 �n%�xNi`(� ?
Cupertino, CA
SUPPORT
P/
OPPOSE
El
SUPPOR
l
OL1
FPPC Form 410 (Dec /2012)
FPPC Advice: advice@fppc.ca.gov (866/275 -3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
Page 3
COMMITTEE NAME I.D. NUMBER
Committee supporting Cupertino Citizens' Se�r5;ble ( =ruwth Ini-ill-;at,oe
4. Type of Committee (continued)
General Purpose Committee 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
Sponsored Committee List additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREETADDRESS NO. AND STREET CITY STATE ZIP CODE
Small • • r Committee li ❑
Date qualified
S Termina1tion Requiremerft Sy signing the verification, the treasurer, assistant treasurer and /or candidate, officeholder, or proponent certify that all of the foNoWng 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 (Dec /2012)
FPPC Advice: advice@fppc.ca.gov (866/275 -3772)
www.fppc.ca.g0v