Form 410
Statement of Organization
Recipient Committee
Statement Type
o Initial
Not yet qualified 0 or
N Amendment
List 1.0. number:
o Termination - See Part 5
List 1.0. number:
TYpe or print In Ink
----1----1_
Date qualified as committee
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Date qualified as committee
(II Ippllcable)
#
----1----1_
Date of Termination
1. Committee Information
NAME OF COMMITTEE
2. Treasurer and Other Principal Officers
NAMJ:: OF TREASURER
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STREET ADDRESS (NO P.O. BOX)
STREET ADDRESS
CITY
STATE
ZIP CODE
AREA CODE/PHONE
CITY
STATE
ZIP CODE
AREA CODElPHONE
NAME OF ASSISTANT TREASURER, IF ANY
MAILING ADDRESS (IF DIFFERENT)
STREET ADDRESS
CITY
STATE
ZIP CODE
AREA CODE/PHONE
OPTIONAL: FAX I E-MAIL ADDRESS
NAME AND POSITION OF OTHER PRINCIPAL OFFICER(S), IF APPLICABLE
COUNTY OF DOMICILE
COUNTY WHERE COMMITTEE 15 ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE
MAILING ADDRESS
Attach additional information on appropriately labeled continuation sheets.
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 knowledge the information contained herein is true and complete. I certify under penalty of
pe~ury under the laws of the State of California that the foregoing is true and correct.
Executed on / /-'1- 0 'l- By
. DATE
Executed on /1-- '/- 07 By
DATE
Executed on By
DATE
Executed on By
DATE
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SIGNATURE OF TREASURER OR ASSISTANT TREASURER
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SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
SIGNATURE OF CONTROLLING OFFICEHOLDER, CANDIDATE, OR STATE MEASURE PROPONENT
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
STATEMENT OF ORGANIZATION
INSTRUCTIONS ON REVERSE
CALIFORNIA 410
FORM
COMMITTEE NAME
/Vt Cf r
COC07 ,- .'(
I.D. NUMBER
I}OO'J~J
4. Type of Committee Complete the applicable sections.
Controffed Committee
· 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.
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT
ELECTIVE OFFICE SOUGHT OR HELD
(INCLUDE DISTRICT NUMBER IF APPLICABLE)
YEAR OF ELECTION
PARTY
o Non-Partisan
'Zoo}'
o Non-Partisan
· List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION
AREA CODElPHONE
BANK ACCOUNT NUMBER
ADDRESS
CITY
STATE
ZIP CODE
Primarily Formed Committee
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)
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 (January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)
Statement of Organization
Recipient Committee
STATEMENT OF ORGANIZATION
INSTRUCTIONS ON REVERSE
CALIFORNIA 41 0
FORM
COMMITTEE NAME
;t1a r
4. Type of Committee
{Jy-
C/ j...
I.D. NUMBER
iCOl(~c,'
1100 1 j'
(Continued)
General Purpose Committee
Not formed to support or oppose specific candidates or measures in a single election. Check only one box:
o CITY Committee 0 COUNTY Committee 0 STATE Committee
PROVIDE BRIEF DESCRIPTION OF ACTIVITY
Sponsored Committee
List additional sponsors on an attachment.
NAME OF SPONSOR
INDUSTRY GROUP OR AFFILIATION OF SPONSOR
STREET ADDRESS
NO. AND STREET
CITY
STATE
ZIP CODE
Small Contributor Committee
o ----1----1_ Check box and provide the date this committee qualified as a small contributor committee. If the committee qualified as a
Date qualified small contributor committee on January 1,2001, enter 111/01.
5. Term ination Requirements By signing the verification, the treasurer, assistanttreasurer andlor candidate, officeholder, or proponent certify that all ofthe 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 (January/05)
FPPC Toll-Free Helpline: 866/ASK-FPPC (866/275-3772)