410 Statement of Organization Recipient Committee - Initial Not Yet QualifiedExecuted on
DATE
Fly
Statement
STATE ME ASLIRE PROI'ONENT
Executed on BV
DATE
SIGNATURE OF CO)ffROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASLIRE I'ROPONENT
FPPC Form 410 (August/2018)
FPPC Advice: advice@fppc.ca.xov {866/275-3772)
www.fppc.ca.gov
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iage rCOMMITTEE NAME
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1.D. NUMBER
a All committees must list the financial institution where the campaign bank account is located.
NAME OF FINANCIALINSTITUTION
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AREA CODE/PHONE
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BANlt ACCOUNT NllMBER
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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 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 CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT
ELECTIVE OFFICE SOUGHT OR HELD
llNCLuDE DISTRICT M)MBER IF APPLICABLE)
YEAR OF
ELECTION
PARTY
CHECKONE
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Nonpartisan
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Parusan (list political party below)
Nonpartisan Partisan (list polibcal party below)
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Listbelow:
CANDIDATE(S) NAME OR MEASUREiS) FuLl TITLE (INCLUDE BALLOT NO. OR LETTER)IF A RECALL, STATE "RECALI IN FRONT OF THE OFFICEHOLOER'S NAME.
CANDIDATEiS) OFFICE SOUGHT OR HELD OR MEASURE(S) ILIRISDICTION
IINCLUDE DISTRICT NO., CITY OR COIINTY, AS APPLICABLE)CHECK )NE
' suppORT OPPOSE
SUPPORT OPPOSE
FPPC Form 410 (August/2018)
FPPC Advice: advice@fppc.ca.Hov (866/275-3772}
www.fppc.ca.gov
Statement of Organization
Recipient Committee
NSTRuCTIONS ON REVERSE
(sCiy iN
Page 3
1.D. NUMBER
ia o ' oo - asr it q = rilnt formed to support or oppose specific candidates or measures in a single eledion. Check only one box:pcm Committee [1 COUNTY Committee [] STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTMTY
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STREET ADDRESS NO. AND STREET CITY STATE ZIP CODE AREA CODE/PHONE
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Date qualified
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 toGovernment Code Section 89519.
Leftover funds of ballot measure committees may be used for polit'cal, legislative or governmental purposes under Government Code Sections 89511-89518, and are subject to Elections Code Section 18680 and FPPC Regulation 18521.5.
FPPC Form 410 (August/2018)
FPPC Advice: advice@)fppc.ca.Hov (866/275-3772)
www.fppc.ca.gov