410
StBt@~l'1@Ilt Of Of'C~]1111Z1t1011 _ STATEMENT OF ORGANIZATION
Type or print in ink Date Stamp
Recipient Committee r ~ • " ' ~
~
Statement Type ? Initial ? Amendment [~ermination - See Part 5 ~ For Offiaal Use Only
Not yet qualified ? or List I.D. number: List I.D. number: ~
# # ~ a~~ ~S 3
Date qualified as committee Date qualified as committee Date of Termination - - - ~ - - - - - ~
(If applicable)
1. Committee Information 2. Treasurer and Other Principal Officers
NAME OF COMMITTEE NAME OF T SURER
~ ~ b~'7"~~•
STREET ADDRESS
C~= M~~ e~ d'~ G1 yw- ~ r L! ~ lG J-~ c ~ S~ ~ ~ rTl / 1 lit
, Li
STREET ADDRESS (NO P.O. BOX) ~ CITY STATE . ZIP CODE AREA CODE/PHONE
~ V~ NAM~ ASS~ST
NT TREASURER, IF ANY ~~J r~
CITY STATE 21P CODE AREA CODEIPHONE
,.P~ t~h ~p C ~fi ~is 46~3~~ ~
~ STREET ADDRESS
MAILING~DDRESS (IF DIFFEREN'n
CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX / E-MAII ADDRESS ~ ~
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE MAILING ADDRESS
~ ~I~ c-(-r
~
CITY STATE ZIP CODE AREA CODE/PHONE
Attach additional 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. I certify under penalty of
perjury under the laws Qf the tate of Califomia that the foregoing is true and correct. w
Executed on ~ v By +
TE SIGNATUREOFTREASURERORASSISTANTTREASURER
Executed on / ~ ~~~1 By -
~ DAT . SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
Executed on By
DATE SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
FPPC Form 410 (January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
Statement of Organization . ~ _ .
Recipient Committee ~ '
Recipient Committee: independent expenditures of $1,000 or more to 24-HourAmendment:
A recipient committee is any individual (including an support or oppose a candidate in that election must If, during the 16 days prior to an election when a
officeholder or a candidate), group of individuals, file the Form 410 (or the information contained on committee is required to file pre-election statements,
the Form 410) within 24 hours of qualification with
organization, or any other entity that receives the filing officer who will receive the committee's a change occurs in the name of the committee; the
contributions totaling $1,000 or more during a treasurer or other principal officers; or the
original disclosure statements and with the filing
calendar year. controlling candidate, an amendment must be filed
officer(s) for the candidate(s) supported or opposed With the filing officer receiving the committee's
The term "contribution" includes monetary by the independent expenditure. These filings must original campaign statements within 24 hours of the
payments, loans and non-monetary goods or be made by fax, guaranteed overnight delivery, change. The amendment must be sent by fax,
services. personal delivery or online (if online filing is onlinetransmission, guaranteed overnightdelivery,
available). or personal delivery. If the Secretary of State is not
Candidates: the filing officeF for the committee's original
The personal funds of a candidate or officeholder Where to File: campaign statements, the amended Form 410 must
used in connection with seeking or holding elective All Committees: also be filed with the Secretary of State within 10
office are contributions and are counted toward Original & one copy Secretary of State days as stated above.
qualifying as a recipient committee. However, Political Reform Division
personal funds used to pay a candidate filing fee or 1500 11th Street, Rm 495 Tel'tflinating:
a fee for the statement of qualifications to appear in Sacramento, CA 95814
the ballot pamphlet are not counted toward the All recipient committees must file disclosure
$1,000 threshold. County & City Committees: statements until the termination requirements are
met and the Form 410 Termination has been filed.
Copy Local filing officer who will See Part 5.
When to File: receive the original
File the Form 410 within 10 days of receiving disclosure statements. This form was prepared by the Fair Political
$1,000 in contributions. The date this form is Practices Commission FPPC For detailed
postmarked is the date it is considered filed. The Secretary of State will assign an identification (
number to the committee. Once assigned, the information on campaign reporting requirements
A recipient committee qualifying during the 16 days identification numberwill be posted on the and the Information PracticesAct of 1977, see the
prior to an election in which it must file pre-election Secretary of State's website (www.ss.ca.gov) and FPPC Campaign Disclosure Manual for your type of
statements must file a Form 410 (or the information written notification will be sent to the committee committee (available from your filing officer or the
required on a Form 410) by fax, guaranteed treasurer. FPPC). Campaign filing deadlines, forms, and
ovemight delivery, or personal delivery within 24 other informational materials are available on the
hours of qualification with the filing officer who will Amending: FPPC website (www.fppc.ca.gov).
receive the committee's original disclosure Except for the "24-hou~' amendment noted below,
statements. A Form 410 must also be filed with the an amendment is due to the Secretary of State and
Secretary of State within 10 days. local filing officer (if applicable) within 10 days from
the date of any change to the information contained
A recipient committee qualifying during the 16 days on the Form 410.
prior to an election in which the committee makes
FPPC Form 410 (January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
~ ?
Statement of Organization STATEMENT OF ORGANIZATION
Recipient Committee ~ ~ ~ ~ ~
INSTRUCTIONS ON REVERSE ' pa9e y
COMMITTEE NAME I.D. NUMBER
(~o ~ M ~ t~c . ~'t k..~ ~ v.i l ~ ~ ~ b5 v ~
4. Type of Committee Complete the applicable sections.
. . .
• 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 "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 CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
! ~ Non-Partisan
R~ ~ C ~ ~ l „~Rrr~ ~u ~ ~ , l
~ Non-Partisan
. List the financial institution where the campaign bank account is located (controlted "candidate e?ection° committees only)
NAME OF FINANCIAL INSTITUTION AREA CODE/PHONE BANK ACCOUNT NUMBER
~.~~~u~~~~ ~33 1-~-7 ~ 40~~-~~7~
~
ADDRESS ~~T~' STATE ZIP CODE
Pu ~ ~x I ~3 ~ ~ r R~~ ~ ~;1,, ~ Lr~ ~ ~ ~ y 3~ ~
, . Primarily formed to support or oppose specific candidates or measures in a single eledion. List below:
CANDIDATE(S) NAME OR MEASURE(S) FULL TITLE (INCLUDE BALLOT NO. OR LETTER) CANDIDATE(S) OFFICE SOUGHT OR HELD OR MEASURE(S) JURISDICTION
(INCLUDE DISTRICT NO., CITY OR COUNTY, AS APPLICABLE) CHECK ONE
SUPPORT OPPOSE
~~i~1 ~~1k ~r Cl`~ C~~~ ~ ~
SUPPORT OPPOSE
FPPC Form 410 (January/O5)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
Instructions for
Statement of Organization ~ - • , ~
Statement Type: box is acceptable for the mailing address. A name or phrase that clearly identifies the
Initial committee's "domicile" is its address as listed on the economic or other special interest of its major
Form 410. Los Angeles is the county of domicile for donors of $50,000 or more. The committee name
The "date qualified" as a committee is the date that ~mmittees located outside Califomia. must also include the name of any candidate that
the committee received contributions totaling $1,000 ~ contributes $50,000 or more. See FPPC
or more during a calendar year. If a Form 410 is The following name identification rules apply to the
filed prior to receipt of $1,000 in contributions, check Form 410, the committee's campaign statements Regulation 18450.3.
the box "Not yet qualified." Once the committee and to any other references to the committee Recall elections: A committee formed by an
qualifies, file an amended Form 410 to report the required by law. See the instructions for Part 4 for officeholder who is the subject of a recall must
date qualified. committee definitions. include the word "recall" in the name of the
committee. A committee primarily formed to
Amendment Legal Defense Fund support or oppose a recall must include the name
If any of the information reported on an initial A state candidate or officeholder who is subject to of the officeholder who is the subject of the recall
statement of organization changes, e.g., change of legal proceedings may establish a controlled and whetherthe committee supports or opposes
treasurers: committee to defray attomey fees and other legal the recall.
• Mark the amendment box. costs. The words "Legal Defense Fund" must be
• Include the committee's ID number and name. included as partofthe committee name. See FPPC 2. Treasurer and Other Principal
• Provide the changed information. Campaign Disclosure Manual 1 for state candidates. OffiCerS:
• Complete the verification.
Sponsored Committees The committee may have only one treasurer and
Unless otherwise prohibited by law, a candidate for A sponsored committee (including most political one assistant treasurer.
local office may amend the Form 410 to indicate that action committees) must include the full name of its If the committee has other principal officers, such
he or she is seeking another term of the same office sponsor in the name of the committee. If the as a president, secretary, or chairperson, list each
(e.g. re-election). A candidate for state office must ~mmittee has more than one sponsor and the officer's full name, position held, and address. Use
open a separate committee for each term of o~ce sponsors are members of an industry or other an appropriately labeled attachment if necessary.
and may not amend the Form 410 to redesignate a identifiable group, include a term identifying that
committee. industryorgroup. 3. Verification:
Termination Primarily Formed Ballot Measure Committees The committee treasurer or assistant treasurer must
A committee primarily formed to support or sign the Form 410.
List the committee's identification number and
indicate the date of termination. oppose a ballot measure must include the Controlled Committees
statement, "Committee For Proposition/ Each controlling officeholder, candidate or state
1. Committee Information: Measure_," or "CommitteeAgainst ballot measure proponent must sign the Form 410.
Proposition/Measure_," in the name of the If more than three con;rol the committee, one of
Provide the full name of the committee. A committee. File an amended Form 410 if the
committee may use only one name. ballot number or letter is not assigned when the them may sign on behalf of all controlling
committee qualifies. individuals. If a candidate will serve as his or her
The committee's street address must be reported. A own treasurer, he or she must sign as the candidate
post office box is not acceptable. The committee's A committee primarily formed to support or oppose and again as the treasurer.
mailing address must also be reported if it is different a ballot measure must also include in its name a
from the committee's street address. A post office FPPC Form 410 (January/05)
FPPC Toll-Free Helpllne: 866/ASK-FPPC (866/275-3772)