410 Statement of Organization Recipient Committee - Termination - Stamped bySOS St�t�ment of Organization DateStamp , ,
Reci�ient Committee �
StatementType \ ' '��''!r�°���a��� °'�'d���� �"��� � -
❑Initial ❑ Amendment Termination—See Part 5 !n 3 he Off C.e Uf t47�:z�Cfet3fy Of uf „ For Official Use Only i I
Not yet qualifed ❑ or List I.D.number. List I. .number: 09 thn SESR�Gf Calif�rnia `i
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Date alifed as committee Date ualified as committee Date of Termination
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1. Committee Information 2:'Treasurer and Other Principal OfFicers
NAME OF COMMITTEE . NAME Of-TRE URER � �
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STREET ADDRESS(NO P.O.BOX)
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S7REETADDRESS�NOP.O.BOX) � /, CITY � STATE ZI`-P� ACOD-IP ONE
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CI7S' S7ATE ZIPCODE AREACODE/P ON � NAMEOf-ASSISTANTTR[ASURER,IFANY �
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MAILI�y'E'i ADDRE55(IF DIFFERENT) / STftEET ADDftESS(NO P.O.BOX) '
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� FAX/E-MAIIADDRE55 L/ CITY STATE ZIPCODE AREAGODE/PHONE
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COUNTY OF DOMICIIE JURISDICTION WHERE COMMITTEE 15ACTIVE NAME OF PRINCIPALOFFICER(5) �
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CITY STATE ZIPCODE 11REACODE/PHONE
Attach addifional 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 un er the laws of the State of California
STATE MEASURE PROPONENT
Executed on gy
DATE SIGNATURE OF CONTROLLING OFFICEIiOLDER,CANDIDATE,OR STATE MEASURE PROPONENT
Executed on gY
DATE SIGNATURE OF CONTROLLING OFFICEFIOLD[R,CANDIDATE,OR STATE MEASURE PROPONENT
FPPC Form 410(Jan/2016)
FPPC Advice;advice@fppc.ca.gov(866/275-3772)
www.fppc.ca.gov
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Statement of Organization • " � '
Recipient Committee • '
INSTRUCTIONS ON REVERSE
Page 2
COMMI•f/�ENAJNE /�/ /� I.D.NUMBER
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• All committees must list the financial institution where the campaign bank account is located.
NAME�OF FIN NCIA NSTITUTIO .
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4. Type o�Commlttee 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 affiiliated 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 CANDIDATE/OFFICEIIOLDER/STATE MEASURE PROPONENT. (INCLUDE DISTRICT NUMBER IF APPLICABLE� YEAR OF ELECTION PARTY
❑ Nonparrisan
❑ Nonpartisan
■.�r,u•u7►.�•���u,���•�,�����t,ta:�l� Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(5)NAME OR MEASURE(S)FULL TITIE(INCLUDE BALLOT NO.OR LETTER) CANDIDATE(S)OFFICE SOUGHT OR HELD OR MEASUREIS)1URISDICTION
(INCLUDE DISTRICT NO.,CITY OR COUNTY,AS APPLICABLE) CHECK OnIE
SUPPORT OPPOSE
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V (J SUPPORT OPPOSE
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/� FPPC Form 410(Jan/2016)
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