410 Statement of Organization Recipient Committee - Termination - Stamped by SOS St�t�ment of Organization DateStamp , � _ ,
Recipient Committee � �
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Statement Type ��nitial ❑ Amendment Termination—See Part S �n S he o(�Ce Uf ti��`s�CrF:t�fy of�fa:i For Official Use Only
Not yet qualified ❑ or
List I.D.number. List I. .number. Q9 thn St2Ra of t;ali?ornia
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1. Committee Information 2. Treasurer and Other Principal Officers
NAMEOFCOMMITTEE . NAME Of-TRE URER �`��
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/ � � ��,�j�,o STftEET ADDR[55(NO P.O.BOX)
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STREETADDRESS�NOP.O.BOX) � CITY � STATE ZIP ODE ACOD /P ONE
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� STATE ZIP COOE AREA CODE/P ON � NAME OF ASSISTANT TREASURER,IF ANY
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MAILIt�Y'i ADDRESS(IF DIFFERENT) / STR[ET ADDftESS(NO P.O.80X� '
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COUNTY OF DOMICILE JURISDICTION WHERE COMMITTEE ISACTIVE NAME OF PRINCIPAL OFFICER(S) �
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CITY STATE ZIPCODE 11REACODE/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 un er the laws of the State of California
STATE MEASUR[VROPONENT
Executed on gY
DAiE SIGNATURE OF CONTROLLING OFFICEIiOLDER,CANDIDATE,OR STATE MEASURE PROPONENT
Executed on gY
DATE SIGNATURE OF CONTROLLING OFFICEHOLOER,CANDIDATE,OR STATE MEASURE PROVONENT
EPPC Form 410(Jan/2016)
FPPC Advice;advice@fppc.ca.gov(866/275-3772)
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www.fppc.ca.gov
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Statement of Organization • ' � '
Recipient Committee • '
INSTRUCTIONS ON REVERSE
Page 2
COMMIyr�ENAJv1E r I.D.NUMBER
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• All committees must list the financial institution where the campaign bank account is located.
NAMF�IOF FIN NCIA NSTITUTIO . AREACODE/PHO E BANKACCOUNTNUMBER
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ADDRE55 � CITY / � STATE ZIPCODE
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4. Type of Committee Complete the applicable sections.
�N.u��u�I Ia�Y�a ui uil��a:�
• List the name of each controlling officeholder,candidate,or state measure proponent. If candidate or oifiiceholder 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"nonpartisan."
• If this committee acts jointly with another controlled committee, list the name and identification number of the other controlled committee.
ELECTIVE OFFICE SOUGHTOR HELD
NAME OF CANDIDATE/OFFICEIIOLDER/STATE MEASURE PROPONENT. (INCLUDE DISTRICT NUMBER IF APPLICABLE) YEAR OF ELECTION PARTY
❑ Nonpartisan
❑ Nonpartisan
■;..r,�v�.�►.�.���,�a�r�r•,�����,�,t:�:� Primarily formed to support or oppose specific candidates or measures in a single election. List below:
CANDIDATE(S)NAME OR MEASURE(5)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
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v � SUPPORT orrose
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FPPC Form 410(Jan/2016)
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