410 Statement of Organization Recipient Committee - Initial 7-12-24DR
AFT
Statement of Organization
Recipient Committee
CALIFORNIA
FORM 410
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASUREPROPONENTDATE
For Official Use Only
1. Committee Information I.D. Number
if applicable)
3. Verification
DATE
DATE
DATE
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 California that the foregoing is true and correct.
Executed on
Executed on
Executed on
Executed on
Date Stamp
CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
By
By
By
By
Statement Type Initial
Not yet qualified
or
Date qualification threshold met
Termination – See Part 5
Date of termination
Amendment
Date qualification threshold met
2. Treasurer and Other Principal Officers
NAME OF COMMITTEE
STREET ADDRESS (NO P.O. BOX)
CITY STATE ZIP CODE AREA CODE/PHONE
COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE IS ACTIVE
FULL MAILING ADDRESS (IF DIFFERENT)
NAME OF TREASURER
NAME OF ASSISTANT TREASURER, IF ANY
Attach additional information on appropriately labeled continuation sheets.
E-MAIL ADDRESS OF COMMITTEE (REQUIRED) / FAX (OPTIONAL)
CITY STATE ZIP CODE
NAME OF PRINCIPAL OFFICER(S)
STREET ADDRESS (NO P.O. BOX)
FPPC Form 410 (October/2023)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
AREA CODE/PHONEEMAILADDRESSOFTREASURER (REQUIRED)
CITY STATE ZIPCODESTREETADDRESS (NO P.O. BOX)
AREA CODE/PHONEEMAILADDRESSOFASSISTANTTREASURER (REQUIRED)
CITY STATE ZIPCODESTREETADDRESS (NO P.O. BOX)
AREA CODE/PHONEEMAILADDRESSOFPRINCIPALOFFICER(S) (REQUIRED)
DR
AFT
Statement of Organization
Recipient Committee
CALIFORNIA
FORM 410
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT
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.
4. Type of Committee Complete the applicable sections.
COMMITTEE NAME I.D. NUMBER
Page2INSTRUCTIONSONREVERSE
Controlled Committee
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER)
IF A RECALL, STATE “RECALL” IN FRONT OF THE OFFICEHOLDER’S NAME.
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
Primarily Formed Committee Primarily formed to support or oppose specific candidates or measures in a single election. List below:
ELECTIVE OFFICE SOUGHT OR HELD
INCLUDE DISTRICT NUMBER IF APPLICABLE)
SUPPORT
PARTY
SUPPORT
OPPOSE
OPPOSE
CHECK ONE
CHECK ONE
YEAR OF
ELECTION
NAME OF FINANCIAL INSTITUTION AND PERSON(S) AUTHORIZED TO OBTAIN BANK RECORDS
ADDRESS OF FINANCIAL INSTITUTION STATE ZIPCODECITY
All committees must list the financial institution where the campaign bank account is located and the person(s) authorized to obtain bank records.
AREA CODE/PHONE BANK ACCOUNT NUMBER
Nonpartisan Partisan (list political party below)
list political party below) Nonpartisan Partisan
FPPC Form 410 (October/2023)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov
DR
AFT
Statement of Organization
Recipient Committee
CALIFORNIA
FORM 410
COMMITTEE NAME I.D. NUMBER
Page3INSTRUCTIONSONREVERSE
5. Termination Requirements
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. Referto
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.
General Purpose Committee Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
List additional sponsors on an attachment.
NAME OF SPONSOR
Sponsored Committee
STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE AREA CODE/PHONE
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
4. Type of Committee (Continued)
By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or ponent certify that all of the following conditions have beenmet:
CITY Committee COUNTY Committee STATE Committee
Date qualified
Small Contributor Committee
FPPC Form 410 (October/2023)
FPPC Advice: advice@fppc.ca.gov (866/275-3772)
www.fppc.ca.gov