410 Initial
STATEMENT OF ORGANIZATION
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Type or print in ink
Statement of Organization
Recipient Committee
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o Termination - See Part 5
List 1.0. number
o Amendment
List 1.0. number:
!i1lnitial
Not
Statement Type
2005
CUPERTINO CITY CLERK
5
AUG
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Date of Termination
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Date qualified as committee
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or
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Date qualified as committee
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qualified
yet
Officers
Princlpa
Treasurer and Other
NAME OF TREASURER
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STREET ADDRESS
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Committee Information
NAME OF COMMITTEE
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AREA CODE/PHONE
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ZIP CODe
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NAME OF ASSISTANT TREASURER, IF ANY
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STREET ADDRESS (NO PO. BOX)
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STATE
AREA CODE/PHONE
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ZIP CODE
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MAILING ADDRESS (IF DIFFERENT)
CITY
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STREET ADDRESS
AREA CODEIPHONE
ZIP CODE
STATE
CITY
ADDRESS
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E-MAIL
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NAME AND POSmON OF OTHER PRINCIPAL OFFICER{S). IF APPLICABLE
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OPTIONAL: FAX
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CC ' OF DOMICILE
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COUNTY WHERE COMMITTEE IS ACTIVE IF DlFFER¡:;NT
THAN COUNTY OF DOMICILE
MAILING ADDRESS
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AREA CODE/PHONE
ZIP CODe
STATE
CITY
certify under penalty of
Attach additIOn a' information on appropriately labeled continuation sheets.
3. Verification
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
perjury under the laws of the State of California that the foregoing is true and correct.
RE OF TREASURER OR ASSISTANT TREASURER
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CEHOlOER. CANDIDATE. OR STATE MEASURE PROPONENT
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Executed on
Executed on
SIGNATURE OF CONTROLLING OFFICEHOLDER. CANDIDPrE, OR STATE MEASURE PROPONENT
FPPC Form 410 (Jan/03)
FPPC Toll-Free Helpline: 866JASK~FPPC
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DATE
DATE
Executed on
Executed on
Statement of Organization
Recipient Committee
D. NUMBER
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INSTRUCTIONS ON REVERSE
COMMITTEE NAME
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4. Type of Committee Complete the applicable sections.
or held, and
ist the elective office sought
is affiliated or check "non-partisan.
list the name and identification number of the other controlled committee,
controlled, also
If candidate or officeholder
state measure proponent
List the political party with which each officeholder or candidate
List the name of each controlling officeholder, candidate, or
district number, if any, and the year of the election.
·
·
this committee acts jointly with another controlled committee,
·
YEAR OF ELECTION PAR TY
--- + -Non-Partisan
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o Non-Partisan
ELECTIVE OFF!CE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE)
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NAME OF CANDID.ATE/QFFICEHOlDERf$TATE MEASURE PROPONENT
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BANK ACCOUNT NUMBER
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STATE ZIP CODe
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is located (controlled "candidate election" committees only)
AREA CODE/PHONE
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CITY
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· List the financial institution where the campaign bank account
OF FINANCIAlIN$TITUTION
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FPPC Form 410 (Jan/03)
FPPC Toll-Free Helpline: 866/ASK-FPPC
Primarily formed to support or oppose specific candidate
CANDIDATE(S) NAME OR ME.