410 Statement of Organization Recipient Committee – AmendmentStatement of Organization
Recipient Com,:.:m.:.:.itta~•-------=---------r:=----"'"""".:'----::---:1
Statement Type D Initial Ill Amendment D Tennlnatlon -See Part 5
0 Not yet qualified
or
0 Date qualification threshold met Date qualificaUon threshold met Date of tennlnatlon
I I ~_o_s _ _,, __ 2022 __ _ _ _,, ___ ,_
Date Stamp CALIFORNIA 41 0
FORM
Fell' Offlctal Us4I Only
1. Committee Information mber 1448574 2. Treasurer and Other Principal Officers
t .....
NAME OF COMMITTEE NAME OF TREASURER
Sheila Mohan For Cupertino City Council 2022 Ram PMohan
STREET ADDRESS (NO P.O. BOXI
mm ADDRESS (NO P.O. BOX) CITY STATf ZIPC0DE AREA CODE/PHONE
Cupertino Ca 95014
CITY STATE ZIP CODE AREA CODE/PHONE NAME OF ASSISTANT TREASURER. IF ANY
Cupertino Ca 95014
FULL MAILING ADDRESS (IF DIFFERENT) STREET ADDRESli (NO P.O. BOX)
HU.IL ADDll£SS (REQUIRED)/ FAX (OPTIONAIJ CITY STAT£ ZIP CODE AREA CODf/l'HONE
JURISDICTION WHERE COMMITTEE IS ACTIVE NAME OF PRINOPALOFflCER(S)
Santa Clara Cupertino
ST11EET ADDRESli (NO P.O. BOX)
Attach additional information on appropriately labeled continuation sheets. CITY STATE ZIP CODE AREA CODE/PHONE
3. Verification
penalty of perju
Executed on f
so able d1hgence in preparing this statement and to the best of my knowledge the information contained herein 1s true and complete. I certify under
Executed on
Executed on
Executed on
under the laws of the State of
OR STAT£ MWURE PROPONENT
DATE By _______ -:::=::-:;:-:::--:::~::::::-:-:::::=:;:=.-:::-::-::::-:::==~======,--------
s1GNATURE OF CONTROLLING OFFICEHOLDER. CANDIDATE, OR STATE MEASURE PROPONENT
DATE By------w,.;;m:..-~:::;:;::~~=~=:-::-=-=-======------SIGNATIJRE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MWURE PROPONENT
FPPC Fonn 410 (August/2011)
FPPC Advice: advlce@fppc.ca.gov (866/275-3772)
www.fppc.ca,gov
Statement of Organization
Recipient Committee
CALIFORNIA 410 FORM
N NR RSE INSTRUCTIO SO EVE
Plp2
CDMWTm NAME I.D.NUMIER
Sheila M>han For Cupertino City Council 2022 1448574
• All mmmhl:ees must 11st the financial Institution where the campaign bank account Is located •
NAME OF FINANCW. INSTIMION AREA CODE/PHONE IIAHK ACCOUNT NUMBER
Wells Fargo Bank
ADDIIESS CITY STATE ZIP CODE
Cupertino CA 95014
4. Type of Committee Comp le te the applicable sections.
Controlled Committee
• List the name of each controlling officeholder, candidate, or state measure proponent. If candldate 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/OFFICEHOLOER/STATE MEASURE PROPONENT
ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE)
YEAR OF
ELECTION
PARTY
CHECK ONE
Sheila M>han Cupertino City Council 2022 Nonpartisan Paftlsan .,
Nonpartisan
Pr,1110,,/y Formed Camm,rtee 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)
IF A RECAU, STATE "RECALL" IN FRONT OF THE OFFICEHOLDER'S NAME.
.,:;-::_r~_.:;
CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE)
Partisan
(list polltlcal party below)
(list polltlcal party below)
CH EC«ONE
SUPPORT OpPOSE
SUPPORT OPPOSE
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
C:OMMITI'Ef NAME
4. Type of Committee (Continued)
CALIFORNIA 41 0
FORM
1.0.NUMIU
Gt'nt!rn' P,11pose Committer Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
D CITY Committee D COUNTY Committee D STATE Committee
PROWlE BREF DESCRIPTIO. ~ ACTIVITY
Soo1•1ort?d Committee List additional sponsors on an attachment.
NAME Of SPONSOR INDUSTRY GROUP 011 AFFILIATION Of SPONSOR
mn:rADDIIESS NO. AND mm CITY STATE ZIPC:ODE AREA CODE/PHONE
Small ContnbLJtor Committee □----Dll!t qu11111od
5. Termination Requirements By signing the verification, the treasurer, assistant treasurer and/or candidate, officeholder, or ponent 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 1\9 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.
FPPC F-orm 410 (August/2018)
FPPC Advice: advice@fppc.ca,gov (866/27S-3m)
www.fppc.ca.gov