410 Statement of Organization Recipient Committee - Amendment �
Statement of Organization D S` P • . • ,
Recipient Committee I
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Statement Type �Initiai �Amendment ❑ Termination-See Part 5 S E P 1 2 2016 �� For ONiclal Use Only
Not yel qualifled❑ of Llst I.D.number; List I.D.number:
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Date quallfled as committee Date quallfied as committee Date of Termination
�11 applicableJ �
1. Committee Informallon 2. Treasurer and Ot ier Principal Officers
NAME OF COMMITTEE NAME OF TREASURER
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NAMEOFWSSISTANT7REASURER,IFANY
(�✓(/�� � 1 �-� � C/�- �l'C CJf`� ���� `] "7 y;�y�14
MAIIING AODRESS(IF DIFFERENT� ' � STREETAODRE55(NO P.O.��%)
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�O�TY OF�OMICILE lURISDICTION WHERE COMMI7TEE IS ACTIVE NAME OF PRINQPAL OFRCER(5) 1 �
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3. Verification
I have used all reasonable d iligence in preparing
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16NATURE OF CONTROILING OFFICEHOIDER,CAND10ATE,OR STATE MEASURE PPOPONENT
Executed on By '
DATE SIGNATURE OF CONTROILING OFFICEHOLDER,ChNDIDATE,OR STATE MEASUOE PROPONENT
Executed on By •
D0.TE SIGNATUPE OF CONTROLLING OFFICEHOIDER,CANDIDATE,OR STATE MEASURE PflOPONENT
FPPC Form 410(Jan/2016)
FPPC Advice:advice@fppc.ca.gov(866J275-3772)
www.fppc.ca.gov
Statement of Organization . � . ,
Recipient Committee � �
� •
INSTRUCTIONS ON ftEVERSE
Page 2
COMMITTEE NAME
I.�,NUMBER
�b P�.� ��k i u S 'T �`1���l2� C. /�� °l���
• All committees must list the financiai institution where the campaign bank account Is located.
NAME OF FINANCIAI INSTITUTION
'
CITY
.. . . .. � , .. . , � �l � I /
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the applicable sections.
d.un u.l la•YbunuO��a:�
� 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 MEASUftE PROPONENT EIECTIVE OFFICE SOUGHT OR HELD
(�NCLUDE DISTRICT NUMBER IF APPLICABIE) YEAROF ELECTION PARTY
I ❑NonpartSsan
I ❑Nonpartisan
■"�""""��������a�■�•����������a� Primari�y formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(5)NAME OR MEASUREIS)FULL TITLE(INCLUDE BALLOT N0,OR LETTER) CANDI DATE(5)OFFICE SOUGHT OR HELD OR MEASURE(S)JURISDICTION
(INCLUDE DISTRICT NO.,CITV OR COUNTV,AS APPLiCABLE�
�.II Al�J�'�'��C C j'P t ZL�V��-j �'P:vl Y[��� � SUPPO�THECK 0 OPPOSE
c�.rcrw r4n i h fi�a��-i�z- -- M���2� �% �U�L-�E I//v C� ; SA'�"�'�i}Lk�� c_c7�N`�V
� SUPPOHT OPPOSE
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o n
FPPC Form 410(Jan/2016)
FPPC Advice;advice@fppc.ca.gov(666/2753772)
www.fppc.ca.gov
Statement of Organization . / - . ,
Recipient Comrnittee • - �
INSTRUCTIONS ON REVERSE
Page 3
COMMIi7EE NAME I.D,NUMBER
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Yp � .��_�� -: � �., _ -� ; �,:�:i �=.�__ ,_ / ��4 y 3 E�
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4. T e f Committ e �co�n
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nued)
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑CITY Committee ❑ COUNTY Committee� STATE Commfttee
PROVIDE BNIEF DESCRIPTION OF ACTIVI7Y
�.i�.����•�.�.,.r�•,.,��.�i.�:.:� List additional sponsors on an attachment.
NAME Of SPONSOR IINOUSTRY GROUP OR AFFlLIATION OF SPONSOR
STREETAD�RE55 NO.ANDSTREET CITY STA7E 21P[ODE
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Date pu�IlNed
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$.Termination Requirements By signing the verificallon,the treasurer,asslstant treasurer and/or candidate,officeholder,or proponent certify that all of the following condltlons 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 inYention 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
CodeSection 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 RegulaHon 185�1.5.
FPPC Form 410(Jan/2016)
FPPC Advice:advice@fppc.ca.gov(866/275-3772)
www.fppc.ca.gov