410 Recipient Committee Campaign Statement 02-14-2011 Statement of Organization STATEMENT OF ORGANIZATION
Type or print in ink natp Stamn
Recipient Committee ��,� CALIFORNIA 410
i ; I i) w ! 7 FORM
Statement Type ❑ initial It Amendment ❑ Termination — See Part For Official Use Only
I.D.
L
Not yet qualified ❑ or
List number: List I.D. number: FEB , in!`) 1
# 1 3 oo38 3 1 U
___i_l g / / i °.7- _/_/ CUPERTINO CITY CLERK
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 TREASURER
/PI It Pk goCh dare
STREET ADDRESS (NO P.O. BOX)
Ma rik ii-l hr CI C.whe,/ Zao,
STREETADDRESS (NO P.O. BOX)
MAILING ADDRESS (IF DIFFERENT)
CITY STATE ZIP CODE AREA CODE/PHONE
OPTIONAL: FAX / E-MAIL ADDRESS /
, NAME OF PRINCIPAL OFFICER(S)
COUNTY OF DOMICILE COUNTY WHERE COMMITTEE IS ACTIVE IF DIFFERENT
THAN COUNTY OF DOMICILE STREET ADDRESS (NO P.O. BOX)
.001 t C /' -'
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 of the State of California that the foregoing is true and correct.
Executed on Z �I (I— / / By '�
DATE ------- SIGNATURE OF TREASURER OR ASSISTANT TREASURER
Executed on
2- —" — / / By
DATE 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 (June /09)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)
Statement of Organization STATEMENT OF ORGANIZATION
Recipient Committee CALIFORNIA 41 0
FORM
INSTRUCTIONS ON REVERSE
Page 2
COMMITTEE NAME I.D. NUMBER
/ 1 1A r l c A l , , y 6 ',- C ( iviu j / 2009 13ao3i
4. Type of Committee Complete the applicable sections.
Controlled 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.
ELECTIVE OFFICE SOUGHT OR HELD
NAME OF CANDIDATE/OFFICEHOLDER/STATE MEASURE PROPONENT (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
tgi f� Non - Partisan
/Gl 1C S� l dwi .1T/` Ci ("4-e r I 2. Do C '41GGr 179/ o Cris} Cov i e f
❑ Non - Partisan
• List the financial institution where the campaign bank account is located (controlled "candidate election" committees only)
NAME OF FINANCIAL INSTITUTION AREA CODE /PHONE BANK ACCOUNT NUMBER
ern 1 A tal a (/Oi) "63-6/00
ADDRESS ,J CITY STATE ZIP CODE
l Z 6 L S • jG �� 2-4. , c `/s ,,e r 77 6 C + qy /
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 (June /09)
FPPC Toll -Free Helpline: 866 /ASK -FPPC (866/275 -3772)