410 Statement of Organization Recipient Committee – Initial Not Yet QualifiedStatement of Organization
Recipient Committee
Statement Type dinitial ❑ Amendment
(Not yet qualified
or
Q Date qualified as committee / I
Date qualified as committee
I.D. Number
(if applicable) _ `
NAME OF COMMITTEE
(, R
4
_Date Stam •
•
" , ')
❑ Termination —See Part 5 For Official Use Only ��
1 / JU2018
Date of termination E
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
MAILING ADDRESS (IF DIFFERENT)
E-MAIL ADDRESS(REQUIRED)/FAX(OPTIONAL) '
.
COUNTY OF DOMICILE
JURISDICTION WHERE COMMITTEE 15 ACTIVE
Attach additional information on appropriately labeled continuation sheets.
2. Treasure)
NAME OF TREASURER
STREET ADDRESS (NO P.O. BOX)
CITY
ZIP
AREACODE/PHONE
NAME OF ASSISTANT TREASURER, IF ANY
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
-
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODEJP HONE
verification =; .
I have used all reasonable diligence in preparing this statement and to the best of my knowledge the inf
penalty of perjury under the laws of the State
STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
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
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
• All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
&msseUg F` - - �
ADDRESS CITY STATE ZIP CODE
Page 2
I.D. NUMBER
4':-T J- egfCornrriitteecomplete the applicable sect)ons:
• 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.
ELECTIVE OFFICE SOUGHT OR HELD YEAR OF PARTY
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) ELECTION
3'
't
_P11G'
LI
SUPPORT
Nonpartisan
Partisan
(listp political party below)
F-1
y-
-
SUPPORT
OPPOSE
El
EL
Nonpartisan
Partisan
(list political party below)
E]
FormedPrimarily formed to support or appose specific candidates or measures in a single election. List below:
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
IF A RECALL, STATE "RECALL' IN FRONT OF THE OFFICEHOLDER'S NAME. (INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
•`Z-
SUPPORT
OPPOSE
F-1
Elq
-
SUPPORT
OPPOSE
El
EL
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
•`Z-
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
Page 3
I.D. NUMBER
yP""niittee:, '(Continued)General Purpose
CommitteeNot 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
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
Sponsored Committee , List additional sponsors on an attachment.
NAME OF SPONSOR INDUSTRY GROUP OR AFFILIATION OF SPONSOR
J
STREET ADDRESS NO. AND STREET CITY STATE ZIPCODE AREA CODEIPHONE
Small Contributor Committee oni
Date qualified
�. TE'riYtt[ialf70t7: R@L(Uir£'rTtentS Ety signing the verification the treasurer, assistant treasur8iand%or candfdate officeholder or.proponertL cert fy that all of the following condttioiis 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 maybe 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.
Clear Page,. Print
FPPC Form 410 (February/2018)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
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