410 termination tatement of Organization
Recipient Committee
Type or print in ink
Date Siam
STATEMENT OF ORGANIZATION
Statement Type [] Initial
Not yet qualified [] or
[] Amendment
List LD. number:
I-- I I
Dale qualified as committee Date qualified as committee
1. Committee Information
[] Termination - See Part 5
List I.D. number:
Date of Termination
2. Treasurer and Other Principal Officers
AREA CODE/PHONE
STREET ADDRESS (NO PC). BOX)
CITY STATE ZIP CODE
MAILING ADDRESS (IF DIFFERENT)
COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
OPTIONAL: FAX / E-MAIL ADDRESS
COUNTY OF DOMICILE
Attach additional information on appropriately labeled continuation sheets.
NAME OF TREASURER
STREET ADDRESS
For Official Use Only
RTINO CITY CLERK
Z~P CODE AREA CODE/PHONE
STREET ADDRESS
CITY STATE ZIP CODE AREA CODE/PHONE
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE
MA~LING ADDRESS
CITY STATE ZiP CODE AREA CODE/PHONE
3, Verification
I have used all reasonable diligence in preparing this statement and to the best of my know~Jg~
perjury under the laws of the State of California that the foregoing is true and correct.~J~"~_.~.~
Executed on /a~/~ ~ /~OAT~ By ~
Executed on ~ ~"'/O ~AAT~E~'''~ By ~
Fn is true and complete. I certify under penatty of
ANT TREASURER
)NTROLLING OFFICEHOLDER, CAND~D~E, OR STATE MEASURE PROPONENT
Executed on By
DATE
SIGNA[URE OF CONTROLLING OFFICEHOLDER, CANDID/~E, OR STATE MEASURE PROPONENT
Executed on By
DATE
SIGN~URE OF CONTROLLING OFFICEHOLDER, CANDIDATE OR STATE M~ASURE PROPONENT
FPPC Form 410 (Jan/03)
FPPC TolI-Frea Heloline: SS~IASK-FPPC
tatement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
4. Type of Committee Complete the appficable sections.
STATEMENT OF ORGANIZATION
Page 2
ID NUMBER
· Listthenameofeachcontrollingofficeholder, candidate, orstatemeasureproponent. Ifcandidateorofficeholdercontrolled, alsolisttheelectiveofficesoughtorheld,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 "non-partisan."
· 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
NAME OF CANDID,~E/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
J~ Non-Partisan
/ [] Non-Partisan
· Listthefinancialinstitutionwherethecampaignbankaccountislocated(controlled candidate election committeesonly)
NAME OF FINANCIAL INSTITUTION
ADDRESS
AREA CODE/PHONE
BANK ACCOUNT NUMBER
I ,'/~/..~ ~. ,~ ~, ,~//
CI~' STATE ZIP CODE
· .. * ~-, ,~. -- 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 LE~FER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO, CITY OR COUNTY, AS APPLICABLE)
CHECK ONE
SUPPORT OPPOSE
SUPPORT OPPOSE
FPPC Form 410 (Jan/03)
FPPC Toil-Free Helpline: 8661ASK-FPPC
Statement of Organization
Recipient Committee
INSTRUCTIONS ON REVERSE
COMMITTEE NAME
4. Type of Committee
STATEMENT OF ORGANIZATION
Page 3
(Continued)
I D NUMBER
'~'' ' o* ' o~ '' Notformedtosupportoropposespecificcandidatesormeasuresinasingleelection. Check only one box:
[] CITY Committee [] COUNTYCommittee [] STATECornrnittee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
List additional sponsors on an attachment.
NAME OF SPONSOR
STREET ADDRESS NO. AND STREET
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
CITY STATE ZIP CODE
Date qualified
· Check box and provide the date this committee qualified as a small conthbut.or committee. If the committee qualified as a
small contributor committee on January 1, 2001, enter 1/1/01.
5. Termination Requirements Bysigning thevedfication, thetreasurer, assistant treasurerand/or candidate, officeholder, or proponent certify that allofthe 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.
FPPC Form 410 (Jan/O3)
FPPC Toll-Free Helpline: 866/ASK-FPPC