410 Statement of Organization Recipient Committee – Initial Not Yet Qualified Stamped by SOSstatement of Organization
tecipient Committe
statement Typenits i ❑Amendment
of yet qualified
or
® Date qualified as committee
Date qualified as committee
. Committee Information I.D. Numbe
(if applicable)
❑ Termination —See Part
in the
Date of termination
Date Stamp
ice of the Secretary of State
the State of California
F
2. Treasurer and Other Principal Officers
NAME OF COMMITTEE
_ �? NAME i
STREET
STREET ADDRESS (NO P.O. BOX)
CITY
MAILING ADD 555 DIFFERENT)
E•MAILADDRESS(REQUIRED)/FAX (OPTIONAL)
COUNTY OF DOM CILE JURISDICr[ON WHER M�MITTEE IS ACTIVE
19,
Attach additional information on appropriately labeled continuation sheets.
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ceaaItvv V. 0DXI
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For Official Use Only
APR - 0, 2018 ,
J_J CUPERTINO CITY CL�RK
pas -- MIT
CITY STATE ZIP CODE AREACODE/PHONE
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREACOOE/PHONE
i. Verification
I have used all reasonable diligence in preparing this
DATE _
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
statement of Organization
tecipie(nt Committee
VSTRUCTIONS ON REVERSE
OMMITTEE
N
All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION
Weils
ADDRESS /
I• • TMG v1 w..;ofu«Cr t-ompiere the applicable sections. -
CommitteeFontrolled I,
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:' Stating "No party preference" is acceptable.
If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee.
NAME OF CAN DIDATE/OFFICEHOLDERJSTATEMEASURE PROPONENT ELECTIVE OFFICE SOUGHT OR HELD YEAR OF PARTY
(INCLUQE DISTRICT NUMBER IF APPLICABLE) ELECTION CHECK ONE
r. /� it r �� i Nonpartis Partisan {list poIltical party
ED
Nonpartisan Partisan (l(st political party
committeePrimarily Formed 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 MEASURES) JURISDICTION
IF A RECALL, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME.
{INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE} CHECK ONE
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
statement of Organization
tecipient Committee
VSTRUCTIONS ON REVERSE
1. Type of Committee (Continued)
GeneralI
PurposeNot formed to support or oppose specific candidates or measures in a single election. Check only one box:
❑ CITY Committee ❑ COUNTY Committee ❑ STATE Committee ❑ Political Party/Central Committee
iOViDE 13RIEF DESCRIPTION OF ACTIVITY
Sponsored Committee List additional sponsors on an attachment.
deer M ceneiene
GROUP OR AFFILIATION OF SPONSOR
Page 3
STATE ZIP CODE AREA
Small Contributor Committee
Date quatifled
i. 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.
Cigar Page Print FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov