410 Statement of Organization Recipient Committee – Initial – Stamped by SOS %-a
Statement of Organization
Recipient Committee
Statement Type 21nitial �,/ El Amendment
Not yet qualified O or List l.D.number:
If
Date qualified as committee Date qualified as committee
(If applicable)
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NAME OF COMMITTEE
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❑ Termination—See Part 5
List I.D.number:
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Date of Termination
STREET ADDRESS(NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
C0-R ev"\M 5-0H
MAILING ADDRESS(IF DIFFERENT)
Date Stamp
RECEIVED AND FILE
in the office of the Socretafy of St±
Of the State of Cgllfomla`
.TUN 15-2016
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CUPERTINO CITY CLEIK
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NAME OF TREASURER
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STREET ADDRESS(NO P.O.BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
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NAME OF ASSISTANT TREASURER,IF ANY
STREET ADDRESS(NO P.O.BOX)
FAX/E-MAIL ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE
COUNTY OF DOMICILE JURISDICTION WHERE.COMMITTEE IS ACTIVE NAME OF PRINCIPAL OFFICER(S)
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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.
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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 Calif 'a that the foregoing is true and correct.
Executed on OU/0 /2011p By
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� �1DATE —� � SIGNATURE OF TREASURER OR ASSISTANT TREASURER
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Executed on V�/C) / 1 7-i�1P By
ATE SIGNATURE OF CONTROLLING OFFICEHOLDER,CANDIDATE,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(Jan/2016)
FPPC Advice:advice @fppc.ca.gov(866/275-3772)
www.fppc.ca.gov
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
C�'�N CWYlC1� Z011p
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
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ADDRESS CITY STATE ZIP CODE
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4.Type of Committee Complete the applicable sections.
Page 2
I.D.NUMBER
• 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:
CAN DIDATE(S)NAME OR MEASU REIS)FULL TITLE(INCLUDE BALLOT NO.OR LETTER)
CANDIDATE(S)OFFICE SOUGHT OR HELD OR MEASURE(S)JURISDICTION
(I NCI IIDF nISTRIrT Nr1 rITV(1D rot IKITV A[ADD]tr AQI 91
Cv eyhl o c C,�C� I
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Nonpartisan
SUPPORT
1:1
❑ Nonpartisan
Primarily Formed Committee Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CAN DIDATE(S)NAME OR MEASU REIS)FULL TITLE(INCLUDE BALLOT NO.OR LETTER)
CANDIDATE(S)OFFICE SOUGHT OR HELD OR MEASURE(S)JURISDICTION
(I NCI IIDF nISTRIrT Nr1 rITV(1D rot IKITV A[ADD]tr AQI 91
FPPC Form 410(Jan/2016)
FPPC Advice:advice @fppc.ca.gov(866/275-3772)
www.fppc.ca.gov
SUPPORT
OPPOSE
SUPPORT
1:1
OPPOSE
EL
FPPC Form 410(Jan/2016)
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
2MV I.D.NUMBER
4.Type of Committee (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
VKUV IUt CKItI-Ut�UKIY I IUN OF ALI
Cow��rn�i � meet �o eolleck i clVlq f iGV1g to s�PPcN� ecko-in �harwaeU ���� tYlo Ci�- Cwnci l
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•• List additional sponsors on an attachment.
NAME OF SPONSOR
STREET ADDRESS NO.AND STREET
CITY
GROUP OR AFFILIATION OF SPONSOR
STATE ZIP CODE
Small Contributor Committee F1
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(Jan/2016)
FPPC Advice:advice @fppc.ca.gov(866/275-3772)
www.fppc.ca.gov